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HomeMy WebLinkAboutAPPLICATION - 08-00372 - 499 S Yellowstone - Call's SinclairCITY OF REXB URG PERMIT # A 3� Z BUILDING PERMIT APPLICATION Please complete the entire Application! 19 E MAIN, REXBURG, ID. 83440 If the question does not apply fill in NA for non applicable 208 - 359 -3020 X322 PARCEL NUMBER: ( We will provide this for you) SUBDIVISION: UNIT# BLOCK# LOT# (Addressing is based on the information - must be accurate) 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: PHONE #: Home ( ) Work ( Cell ( ) CONTRACTOR MAILING ADDRESS: p. ��_�� CITY Z�bu� STATE -�-� ZIP 93;0D PHONE: Home# Work# Cell# :370 _ � EMAIL FAX : 554 — SOSS 1W uiaiiy uui lulllgs are locaiea on inls 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: (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 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, 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 Permit Fees are due at time of application" "Building Permits are void if you check does not clear" ZIP EMAIL CITY: FAX MO N *0 Dal COMMUNITY DEVELOPMENT >' DEPARTMENT L. Main ox Phone: 208- 359 -3020 x326 Rexburg, Idaho 83440 Fax: 208 - 359 -3024 www.rexburg.org comdev(a)rexburg.org Affidavit of Legal Interest State of Idaho County of Madison I, toar:n M �o.l'� c_I�« •x.11 O ��l LL �q S �..9./ Name Address A —=c4 1,e City State Being first duly sworn upon oath, depose and say: (If Applicant is also Owner of Record, skip to B) A. That I am the record owner he propert described n the attached, and I rant my permission to: �O 7 y ,� q 7 Name Address to submit the accompanying application pertaining to that property. B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any claim or liability resulting from any dispute as to the statements contained herein or as to the ownership of the property which is the subject of the application. Dated this ,0 3 day of 7:3� 1� 20 © fr Signature Subscribed and sworn to before me the day and year first above written. �Q .' 9 .,� OZ Notary Public daho Residing at: VB L%G .... P��.�` My commission expires: l�— OF P ^sue 0 'lease complete the tirc pplicit o _ n . r ..` ., • It' the question does not apply fill in NA for non ipplic.,Ihle NAME PROPERTY ADDRESS SUBDIVISION Dwelling Units: SETBACKS F RONT SIDE Parcel Acres: SIDE BACK Remodeling Your Building/Home (need Estimate) $ SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building) First Floor Area Second floor /loft area Third floor /loft area_ Shed or Barn Unfinished Basement area Finished basement area Garage area Carport/Deck (30" above grade)Area Water Meter Quantity: r :� : � ,k : :, Water Meter Size: Required!!! PLUMBING Plumbing Contractor's Name: Address Contact Phone: ( ) Email FIXTURE COUNT (including roughed fixtures) Clothes Washing Machine Dishwasher Floor Drain Garbage Disposal Hot Tub /Spa Sinks (Lavatories, kitchens, bar, mop) Business Name: City Business Phone: Fax Permit# 1 State Zip Sprinklers Tub /Showers Toilet/Urinal Water Heater Water Softener Plumbing Estimate $ (Commercial Only) Signature of Licensed Contractor License number Date The City of Rexburg's permit fee schedule is the same as required by the State of Idaho P1eAS6e ihpk th& e 1 6 1Ca 1� If the question does not apply fill in NA for non applicable NAME Co� at 'W A Gild 1 PROPERTY ADDRESS S e s �o v� Permit# SUBDIVISION Required!!! MECHANICAL Mechanical Contractor's Name: 51-eye ua fte u Business Name: Address Q ©X City e State T_ Zip 934Ap Contact Phone: ( ) Business Phone: q09) S to - ) 4 ► 11 Email Fax `_:� Sin - eta SS Mechanical Estimate $ 3 ?0 Q � (Commercial/Multi Family Only) FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only) Furnace Exhaust or Vent Ducts Furnace /Air Conditioner Combo Heat Pump 1 Air Conditioner Evaporative Cooler Unit Heater Space Heater Decorative gas -fired appliance Incinerator System Boiler Pool Heater Similar fixtures or Appliances _ I Fuel Gas Pipe Outlets including stubbed in or future outlets Inlet Pressure (Meter Supply) PSI Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Dryer Vents Range Hood Vents Cook Stove Vents Bath Fan Vents other similar vents & ducts: Mechanical Sizing Calculations must be submitted with Plans & Application Point of Delivery must be shown on plans. z..%" Hoaftj Signature of Licensed Contractor The City of Rexburg's +H -G- La aq ?- Z 0 - tie License number Date fee schedule is the same as required by the State of Idaho