HomeMy WebLinkAboutAPPLICATION - 08-00366 - 9200 Outlaw Pass - HillCITY OF REXBURG 0 0
0800366
MECHANICAL PERMIT APPLICATION Please
19 E MAIN, REXBURG, ID. 83440 O �� e que, 924JOutIaW Pass -Hit
208 - 359 -3020 X326 V W V � �
PARCEL NUMBER: t,(, �- �� ( We will provide this for you) �.
SUBDIVISION: - { \e c ;�a �-}-- UNIT# 3 BLOCK# LOT# J
(Addressing is based on the information - must be accurate)
OWNER: CONTACT PHONE #
PROPERTY ADDRESS: 9 ;)-UQ S. n Ct- I WvJ -P
PHONE #: Home 04'9) � `1� - x.3 Work (.2-,q_s0 S5 -&60 7 Cell ( ) SR - 7 7 I3
OWNER MAILING ADDRESS: P 119 CITY: ReXlgtk . STATE: -- ZIP: 3 6
EMAIL FAX 3>57 [S
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
STATE; ZIP
PHONE #: Home (
ADDRESS CITY:
EMAIL �" FAX
Work ( ) ��c) Cell ( )—
CONTRACTOR
MAILING ADDRESS:
PHONE
// i Work#
Vt
�' CITY v / f
Cell# �ZO
EMAIL N FAX TZZ 7 - 0 13
How many buildings are located on this Dronertv? 0 r
STATE_JP ZIP/
Did you recently purchase this property? No <&If yes give owner's name)
Is this a lot split. NO YES (Please bring copy of new legal description of property)
PROPOSED USE: S "i VYA (�P-
(i.e., Single Family Residence, Multi Family, Apartments, Re
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 applicatior�.,ur.Qn 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.
r1t / 2 / Q
Signature of Owner /Applicant D TE
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
Building Safety Department _ �Q��st,kr
CI OF
City of Rexburg n TvnT mG
.1�.GL\17 V 1\
19 E Main ioneiih @rexburg.org Phone: 208.359.3020 x326 mil
America's Famil Community
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
NAME
PROPERTY ADDRESS 'T,4- Permit#
SUBDIVISION teu g I tz r5�1
Required!!! MECHANICAL
Mechanical Contractor's Name: + q s iA l b , 01 wVL Business Name:
Address YS EA0 s V City ____ . State J�, Zip �I
Cell Phone: Q 8 5_�_ I S 3 J Business Phone: 5 , �L �- 27 1 4
Fax: (
Email
Mechanical Estimate $; ` (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
2_ Furnace /Air Conditioner Combo Dryer Vents
Heat Pump Range Hood Vents
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
./ — Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
_4- 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.
S ature of Lic ns ontractor icense number Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho