HomeMy WebLinkAboutAPPLICATION - 08-00533 - 145 S 2nd E - ThomasonCITY OF REXB URG PERMIT #
BUILDING PERMIT APPLICATION Please complete the entire Application r
19 E MAIN, REXBURG, ID. 83440
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)
OWNER NAME: i s T o r" a CONTACT PHONE #
PROPERTY ADDRESS:
PHONE #: Home f� 01 3 �� y f Work ( ) Cell ( )
OWNER MAILING ADDRESS :,S S' y3CO id CITY: r ho; r STATE: � ZIP: S�yLj
EMAIL FAX
APPLICANT (If other than owner) a f
(Applicant if other than owner, a statement authorizing applican o act as ent for owner must accompany this application.)
APPLICANT INFORMATION: ADDRESS ge/ N '74 ze CITY:
STATE; / ZIPY:3WO EMAIL
PHONE #: Home 0' !S S/ /// Work
FAX
Cell ( )
CONTRACTOR: rVe a/r
MAILING ADDRESS:? 0 f /sax 5 CITY L 4I- ' STATE yS�G
PHONE: Home# Work #3� - 4 , V '111 Cell#
EMAIL FAX
T T 1
lruw uiauy vulrurngs are loca on this 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
pe preva� s . Permit void if not std 6 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"
Y
If the question does not apply fill in NA for non applicable
,
�R CITY F
RR.EXBUR -G DEPARTMENT
COMMUNITY DEVELOPMENT
• '� qs �� AMERICA'S FAMILY COMMUNffY 19 E. Main (PO Box 280) Phone: 208 - 359 -3020 x326
Rexburg, Idaho 83440 Fax: 208 - 359 -3024
www.rexburg.oro comdevarexburo.ora
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
City
Being first duly sworn upon oath, depose and say:
Address
State
(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:
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 � d Z� day of l 20
Subscribed and sworn to before me the day and year first above written.
6 ' "` otary Public of Idaho
Residing at:
My commission expires: - 26 — c;30 7
O�`
Please complete'the eti €ifi ......
If the question does not apply 1 in NA for• nun j jppjieal)le
NAME
PROPERTY ADDRESS � -f � ` , x�� Permit#
SUBDIVISION
Dwelling Units: Parcel Acres:
SETBACKS
FRONT SIDE SIDE BACK
Remodeling Your Building/Home ( need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfinished Basement area
Second floor /lo area 4 L Finished basement area_
Third floor /loft area Garage area
Shed or Barn Carport/Deck (30" above g
Fax
Water Meter Quantity:
* >k * * ,;, * a: a: * :r * * :r Water Meter Size:
Requ red11 !
PLUMBING
Plumbing Contractor's Name: Business Name:
Address City - /V
Contact Phone: ( ) Business Phone: ( )
Email
FIXTURE COUNT (including roughed fixtures)
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub /Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
(Commercial Only)
Signature of Licensed Contractor License number
The City of Rexburg's permit fee schedule is the same as
Sprinklers
Tub /Showers
Toilet/Urinal
Water Heater
Water Softener
Date
by the State of Idaho
)Area
State Zip
Please cbinplete"the en >< e pp� ca io57 f
applicable
NAME
() /rI PROPER ADDRESS ���, �'
SUBDIVISION
e question does not a
Permit#
in NA for non
Required!!! MECHANICAL
Mechanical Contractor's Name: Yr/ 11 , 1 1e - 11 Business Name:
Address Q/ 11 City e State zi
Contact Phone: ( ) Business Phone: app
Email
Fax =
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
Pool Heater
Similar fixtures or Appliances
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) as 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.
ature of Licensed Contr *tor
The City of Rexburg's
/999
License number
schedule is the same as
/0 3o -- 09
Date
by the State of I daho
................................. ............................... a E 0 a E 0 ..... a a R 0 0 0 ...... 0 a a a 1
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:
Masonry:
Roofing:
Insulation:
Drywall:
Painting:
Floor
Coverings:
Plumbing:
Heating:
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor /Ceiling Joists:
Siding/Exterior Trim:
Other: