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Home My WebLink AboutAPPLICATION - 08-00474 - 136 Syringa St - Covered Deck - CANCELEDoQ 8E X A C'q CITY O F� a REXBURG Ow "•<, America's Family Community «F - v Please CompleWthe Entire Application! RESIDENTIAL BUILDING PERMIT APPL 136 Syringa St- Covered Deck 19 E MAIN, REXBURG, ID 83440 208 - 359 - 3020 X326 PARCEL NUMBER: Oft c� �� 1 7 (We will provide this for you) SUBDIVISION: UNIT# BLOCK# LOT# (Addressing is based on the information - must be accurate) Dwelling Units: Parcel Acres: OWNER NAME A v A CONTACT PHONE # 3 si- 4 i a PROPERTY ADDRESS: / 3 r v2ana 9 T PHONE #: Home ( ) Work ( ) Cell (Zo� 3 l - o ci OWNER MAILING ADDRESS: l 3 /� SYRzwGA. `, r CITY: Q STATE: ° M; ') ZIP: �'L 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 Ho VreLF'r ST CITY: a,?_xh%&%- STATE; r7 c) ZIP k3 4qQ EMAIL FAX PHONE #: Home ( ) Work ( ) Cell (/) 208 - 3Sj - G (zO9 CONTRACTOR MAILING ADDRESS: CITY STATE ZIP PHONE #: Home ( ) Work ( ) Cell( ) EMAIL FAX IDAHO REGISTRATION # & EXP. DATE How many buildings are located on this nronerty? Did you recently purchase this property? No Yes (If yes, list previous 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 2003 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. , t, 5; 7 a, ,, - c l.�.r- 'I / L (, / 2,00 Signature of Owner /Applicant DATE 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 ranuary 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 your check does not clear** Bull g Safety Departmen City of Rexburg 19 E. Main Rexburg, ID 83440 janellh@rexburg.org Phone: 208.359.3020 www.rexburg.org Fax: 208.359.3024 U y0 CITY O F i E BUR .. - ..____ OW _ ------ ----- _- America's Family Community Affidavit of Legal Interest State of Idaho County of Madison I, ,SF - / f Y12) Ig Name Address I/ 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 of the property described on the attached, and I grant my permission to: _ te f r „o J ese t'3 1. s A 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 day of , 20 Signature Subscribed and sworn to before me the day and year first above written. Notary Public of Idaho Residing at: My commission expires: Building Safety Department o �ExBL�� r City of Rexburg � o 19 E. Main ionellh@rexburg.org Phone: 208.359.3020 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 C I T Y OF REXB V RG 1 _ CW . _ — America's Family Community Remodeling Your Building /Home ( need Estimate $ ? a O o o SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building) First Floor Area Unfinished Basement area Second floor /loft area Finished basement area Third floor /loft area Garage area Shed or Barn Carport /Deck (30" above grade)Area L-/ Water Meter Quantity: * * * * * * * * * * * ** *Water Meter Size: RequiredhY PLUMBING Plumbing Contractor's Name: Business Name: Address City State Zip Contact Phone: ( ) Business Phone: ( ) Email Fax FIXTURE COUNT ('including roughed fixtures Clothes Washing Machine Sprinklers Dishwasher Tub /Showers Floor Drain Toilet /Urinal Garbage Disposal Water Heater Hot Tub /Spa Water Softener Sinks (Lavatories, kitchens, bar, mop) Plumbing Estimate $ (COMMERCIAL /MULTI - FAMILY ONLY) Signature of Licensed Contractor The License Number& Expiration Date Date schedule is the same as required by the State of Idaho Building Safety Department City of Rexburg 19 E. Main ionellh@rexburg.org Phone: 208.359.3020 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 o� �r.xs V v` o '+EO C I T Y OF REXBURG America's Family Community NAME PROPERTY ADDRESS SUBDIVISION PHASE LOT BLOCK Permit# RequiredLY MECHANICAL Mechanical Contractor's Name Business Name Address City State Zip Cell Phone ( ) Business Phone ( ) Fax ( ) Email Mechanical Estimate $ (Commercial /Multi Family Only) I FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only) Furnace Furnace /Air Conditioner Combo Heat Pump Air Conditioner Evaporative Cooler Unit Heater Space Heater Decorative gas -fired appliance Incinerator System Boiler Pool Heater Fuel Gas Pipe Outlets including stubbed in or future outlets Inlet Pressure (Meter Supply) PSI Exhaust or Vent Ducts Dryer Vents Range Hood Vents Cook Stove Vents Bath Fan Vents other similar vents & ducts: I Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic Signature of Licensed Contractor The License number schedule is the same as the State of Idabo Date Building Safety Department City of Rexburg 19 E Main janellh @rexburg.org Phone: 208.359.3020 x326 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 of Reza URC �4 �O 7 v o C IT Y OF REXBURG Americas Family Community OWNER'S NAME PROPERTY ADDRESS SUBDIVISION PHASE LOT BLOCK Home Phone ( ) HOME OWNER - S ELECTRICAL PERMIT Home Owner's Name Address City State Zip Cell Phone ( ) Fax ( ) TYPES OF INSTALLATION (New Residential includes everything contained within the residential structure and attached garage at the same time) 0' For power supplier requirements visit www.rockymtnpower.net Number of meters being installed Up to 200 amp Service* 201 to 400 amp Service* Over 400 amp Service* Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year) Existing Residential (# of Branch Circuits) Spa, Hot Tub, Swimming Pool Electric Central Systems Heating and /or Cooling (when not part of a new residential construction permit and no additional wiring) Modular, Manufactured or Mobile Home Other Installations: Wiring not specifically covered by any of the above Cost of Wiring & Labor: $ Pumps (Domestic Water, Irrigation, Sewage) Requested Inspections (of existing wiring) Temporary Amusement /Industry *Includes a maximum of 3 inspections. Additional inspections charged at requested inspection rate of $40 per hour. Signature of Home Owner The City Permit# Date schedule is the same as required by the State Building Safety Department o AtiXAURj�, City of Rexburg c o 19 E Main jonellh@rexburg.org Phone: 208.359.3020 x326 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 CITY OF REXBURG Americas Family Community OWNER'S NAME PROPERTY ADDRESS SUBDIVISION PHASE LOT BLOCK Permit# RequiredN ELECTRICAL Electrical Contractor's Name Business Name Address City State Zip Cell Phone ( ) Business Phone ( ) Fax ( ) Email Electrical Estimate ( cost of wiring & labor $ (COMMERCIAL /MULTI - FAMILY ONLY) TYPES OFINSTALLATION (New Residential includes everything contained within the residential structure and attached garage at the same time) Number of meters being installed Up to 200 amp Service* 201 to 400 amp Service* Over 400 amp Service* Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year) Existing Residential (# of Branch Circuits) Spa, Hot Tub, Swimming Pool Electric Central Systems Heating and /or Cooling (when not part of a new residential construction permit and no additional wiring) Modular, Manufactured or Mobile Home Other Installations: Wiring not specifically covered by any of the above Cost of Wiring & Labor: $ Pumps (Domestic Water, Irrigation, Sewage) Requested Inspections (of existing wiring) Temporary Amusement /Industry *Includes a maximum of 3 inspections. Additional inspections charged at requested inspection rate of $40 per hour. Signature of Licensed Contractor The License number schedule is the same as Date the State • SUBCONTRACTOR LIST Excavation & Masonry: Insulation: Painting: Floor Roof Trusses: Floor /Ceiling Joi Special Construction (Manufacturer or Supplier) Siding /Exterior Trim: J EXEMPTIONS FROM STATE REGISTRATION As of January 1, 2006, the City of Rexburg can no longer sell permits without having a copy of your State registration number or your exemption from the State registration. Please send a copy of your state registration or fill out this form showing your exemption and send it with your license renewal or your next permit application. (This list is a summarization of Idaho Code Title 54 Chapter 5205, for full definitions of these exemptions please see the State's website at www.ibol.idaho.eov /cont htm ❑ Currently State licensed pursuant to Tide 54 Idaho Code, Chapters: 3 Architects, 10 Electrical Contractors /Journeyman, 12 Engineers /Surveyors, 19 Public Works Contractors (exempt from fee only registration required), 26 Plumbing /Plumbers, 45 Public Works Construction Management Licensing Act (exempt from fee only registration required), or 50 Installation of heating, ventilation and air conditioning systems ❑ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit charitable activity with no wages or salary ❑ Employee of a US Government agency (State, City, County, or other municipality) ❑ Public Utility doing construction, maintenance, or development to its own business ❑ Involved with gas, oil or mineral operations ❑ Supplier doing no installation or fabricating ❑ Contracting a project or projects with a total cost less than $2000 ❑ Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building Code ❑ Any type of water district operations ❑ Work in rural districts for fire prevention purposes ❑ Owner who performs work on own property or contracts with a registered contractor to do work as long as the property is not for resale within 12 months R1 Owner or lessee of commercial property performing maintenance, repair, alteration or construction on that property ❑ Real estate licensee /property manager acting within Idaho Code ❑ Engaging in the logging industry ❑ Renter working on the property where they live with the property owners approval ❑ Construction of a building used for industrial chemical processing per Idaho Code ❑ Construction of a modular building (defined by Idaho Code) to be moved out of state I hereby certify that the above information is true and correct to the best of my knowledge. Signature 2 Date AN 1 er,r n VFA R Print Name