HomeMy WebLinkAboutAPPLICATION - 08-00212 - 1670 W 3000 N - Mechanical• •
GITY OF REXBURG PERK
MECHANICAL PERMIT APPLICATION Please comp 0800212
19 E MAIN, REXBURG, ID. 83440 If the question doi
208 - 359 -3020 X326 G q Juan Oldham 1670 W 3000 N
PARCEL NUMBER- �G.�� 1 We will
SUBDIVISION: e UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: B. / �f1 v� CONTACT PHONE # $ 6,5-1 go 3 3
PROPERTY ADDRESS: 57 3c c
PHONE #: Home ( ) � Work ( ) r--- _. Cell (24 ('?/
OWNER MAILING ADDRESS: 1& CITY: STATE ZIP: '93 y 1 7�
EMAIL FAX
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 CITY:
STATE; ZIP EMAIL FAX
PHONE #: Home ( ) Work ( ) Cell ( )
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL 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 split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE: /P -A '
(i.e., Single Family Residence, N Family,
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjur 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 approv ed under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the 4lication or on the plans �o whic rmit or proval was based. Permit void if not started within 180 days. Permit void
� stops for 180 days. �^
/ l / 2 O
S,ifnature of Owner /Applicant DATE
o 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
Building Safety Department
City of Rexburg
19 E Main
Rexburg, ID 83440
NAME .., at-7 13 .. c �
PROPERTY ADDRESS
SUBDIVISION
a
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City State
Cell Phone: ( ) Business Phone: ( )
Fax: ( ) Email
M echanical Estimate $ (Commercial/Multi Family Only)
NG.
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace
Exhaust or Vent Ducts
Furnace /Air Conditioner Combo
Dryer Vents
Heat Pump
Range Hood Vents
Air Conditioner
Cook Stove Vents
Evaporative Cooler
Bath Fan Vents
Unit Heater
other similar vents & ducts:
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
Fuel Gas Pipe Outlets including stubbed in or future outlets
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 Contractor License number
janellh @rexburg.org Phone: 208.359.3020 x326
www.rexburg.org Fax: 208.359.3024
C I T Y O F
REXBURG
__. ___ C , _.____
America's Family Community
`;04 pkxa vAC lO
V N � O
Zip
Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho