HomeMy WebLinkAboutAPPLICATION - 08-00111 - 2861 W 5200 S - Mechanicality o, f Rexburg/ Madison County
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208- 359 -3020 X322
PERMIT # •
l' L4i= i(u:t
PARCEL NUMBER W,Z` `Vaq Eon _ ( We
SUBDIVISION: UNIT
(Addressing is based on the information - must be accurate)
0800111
2891 W 5200 S- Walker
(Temporary Addre
PROPERTY ADDRESS:
PHONE #: Home 05K ) s66 - 1l,/� _ Work W) 35 Cell (A 35[
OWNER MAILING ADDRESS: a-n Gel 50m S CITY: u!'a_STATE:TZIP V(-/
EMAIL IR okb X ►v► 1 _ 6b CAL ►° ( os) 56 - % i A T 00-11
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APPLICANT (If other than owner)
(Applicant if other than owner, a statement
applicant to act as agent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL
PHONE #: Horne (
CITY:
FAX
Wo ) )
CONTRACTOR
MAILING ADDRESS: CITY
PHONE: Home#
Work#
EMAIL FAX
STATE ZIP
How many buildings are located on this property? 11�
Did you recently purchase this property? NJ Yes (If yes give owner's name;
Is this a lot split? NO S (Please bring copy of new legal description of property)
PROPOSED USE: c 1ci jvVI k - kL
(i.e., Single Family Residence, Multi Family, Apaiiiients, Rem el, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION Under penalty of pedury, 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 2000 International Code in cases of any false statement or
misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not started within 180 days. Permit void if work
stops for 180 days.
Signature of Owner /Applicant DATE
Do you prefer to be contacted by fax, entail 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.
Cell#
2