HomeMy WebLinkAboutAPPLICATION - 08-00238 - 5176 S 4300 W - MechanicalCITY OF REXBURG • PERMIT # •
MECHANICAL PERMIT APPLICATION Please c 08 0023 8
19 E MAIN, REXBURG, ID. 83440 If the questi
208- 359 -3020 X326 5176 S 4300 W - Hansen
PARCEL NUMBER: f � � S2_ O�"� (W,
SUBDIVISION: UNI1,,
(Addressing is based on the information - must be accurate)
OWNER: CONTACT PHONE #
PROPERTY ADDRESS:
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS: �/ �� ' CITY: STATE:,efZIP:_1�
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
PHONE: Home# J `OVork# ' r� Cell# 'Jj /7 ° ,
EMAIL FAX
How many buildings are located on this property?
Did you recently purchase this property? No Yes (If yes give owner's name)
STATE,, ZIP
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE:
(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 Ci 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 appfication and hereby au o i representatives of the City to enter upon the above - mentioned property for inspections purposes. NOTE: The
building official 41ay r9foke a permit on appr al ed under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the application orlon Ae plans o whidi the ppr al was based. Permit void if not started within 180 days. Permit void if work stops for 18 da
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Signature o caner/ licant P
Do you prdfer 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 jonellh @rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!! MECHANICAL
ICI
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Mechanical C ntractor's Name: 9 �' / � {A ' Busin ss ame:
Address ity State - -� � ( A — Zl p_& r ' 5 �
Cell Phone: Business Phone:
Fax: (
Email
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace /Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Pool Heater
Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Mechanical Siziny- Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
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S gna e of Lken f ontractor & License number V Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho