HomeMy WebLinkAboutAPPLICATION - 08-00052 - 2860 W 5200 S - MechanicalCITY OF REXBURG
MECHANICAL PERMIT APPLICATION Please
19 E MAIN, REXBURG, ID. 83440 If the que
208 - 359 -3020 X326
•
0800052
2860 W 5200 S -Shop
PARCEL NUMBER: "�, 9 ,q &a? P4 ( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
UWIVE c: L) , t_ . -1 CONTACT PHONE #
PROPERTY ADDRESS (,, b h) �,a p p
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PHONE #: Home �' Work (206 Cell
OWNER MAILING ADDRESS: h2()1 S_ V100 v✓ . CITY:
EMAIL
FAX
li� )eE;Uec, STATE b ZIP: 44 r,-
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL
PHONE #: Home (
Work (
Cell (
CONTRACTOR IVIQLY X�-1 hj W 5
MAILING ADDRESS: Z (p �, 520c� . CITY Y [)(8U 0l STATEZIP
PHONE: Home# , 120K � W ork# 3 S5_6 -65!76 Cell# S
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EMAIL 6 17460fY1 yV.j j,t FAX
How many buildings are located on this property?
Did you recently purchase this property? No Yes (If yes give owner's name)
Is this a lot splAEip YES (Please bring copy of new legal description of property)
PROPOSED USE: (ice YYN n - ) MR-C 1 4 L_
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION Under penalty of perjury, I hereby certify that I have
read this application and state that the information herein is correct and I swear that any information which may hereafter be given by me in hearings before the Planning
and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply with all City regulations and State laws relating to the
subject matter of this application and hereby authorized representatives of the City to enter upon the above - mentioned property for inspections purposes. NOTE: The
building official may revoke a permit on approval issued under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the applic ion of o f on which lrit er-epprova }wag tMed. Permit void if not started within 180 days. Permit void if work stops for 180 days.
0 i i
Signature of Applicant DATE
Do you prefer to be contacted by fax, email or phone? Circle One
WARNING — BUILDING PERMIT MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non - refundable and are paid in full at the time of application beginning January 1. 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
CITY:
FAX
Building Safety Department
City of Rexburg
19 E Main jonellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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C I T Y OF
REXBURG
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America's Family Community
NAME Ill L
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PROPERTY ADDRESS 1-S&O 62,00 .Sy
SUBDIVISION
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: AU , i VI//r (JW4 Business Name: /Vll)f TiPtJ
Address Z��3(� )AE , � U -' City Re- State j Zip d
Cell Phone: ( pgf '2? C10 ¢ -Z 0 ( Business Phone: (age
Fax: (/fv g5 — Email
Mechanical Estimate $ / Qa (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
Furnace 3 Exhaust or Vent Ducts
Furnace /Air Conditioner Combo
Heat Pump
Air Conditioner
l ,Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
Fuel Gas Pipe Outlets including stubbed in or future outlets
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature of Licensed
The City of
'A 41 s /zco
License number
's permitfee schedule is the same as
the State of Idaho
Date