HomeMy WebLinkAboutAPPLICATION - 08-00465 - 7860 S 400 W - Mad City Fire Protectiont 'k-
CITY OF REXBURG PERMIT #
MECHANICAL 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 X326
PARCEL NUMBER: ( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: CONTACT PHONE #
PROPERTY ADDRESS: -7 9 &-) S y�
PHONE #: Home Work
OWNER MAILING ADDRESS:
EMAIL
FAX
CITY:
STATE: ZIP:
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; ZIP EMAIL
PHONE #: Home ( )
Work (
Cell (
Cell (
CITY:
FAX
CONTRACTOR
MAILING ADDRESS: 37
PHONE: Home#
EMAIL
€- T\&J CITY 4�W STATE
Work# 2 9L Cell#
_FAX 2 4� — 137Y
How many buildings are located on this Dronertv?
ZIP ei Yn /
Did you recently purchase this property? Oo 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: cj � LP, a,,
(i.e., Single Family Residence, Multi
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: under penalt of perjur I hereb certif 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 thi p ication and hereby authorized representatives of the City to enter upon the above - mentioned property for inspections purposes. NOTE: The
building official y rev e a it on approval issued under the provisions of the 2003 International Code in cases of any false statement or misrepresentation of fact in
the application o on ans whip4e p mit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
Signature
Do you
Owner/
Or? / / C_>,
DATE
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 ionellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
NAME , t
PROPERTY ADDRESS _
SUBDIVISION
OF gExs uRC
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CITY O F
REXBURG
America's Family Community
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Permit#
Required!!! rG MECHANICAL
Mechanical Contractor's Name: ' Business Name:
Address 3 7 -� Nc�C.lesa Cit �-
Y - State r'y Zip
Cell Phone: (zmjr) s f 'g9 — 3 70 c / Business Phone: (2oY- s'ZS 9,33
Fax: (2141 - Email
Mechanical Estimate $ 2-5 CO. z (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
Pool Heater
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
Point of Delivery must be shown on plans.
Signature of Licensed Contractor
The City
NO
License number
's permit fee schedule is the same as
(� 2 Y ��
Date
y the State of Ida