HomeMy WebLinkAboutAPPLICATION - 08-00557 - 164 W 1st N - MechanicalR CITY OF REXBURG •
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208 - 359 -3020 X326
PERMIT #
Please complete the entire Application!
If the question does not apply fill in NA for non applicable
PARCEL NUMBER: ( We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
OWNER: 6n4 in CONTACT PHONE #
PROPERTY ADDRESS: _AY AZ
PHONE #: Home ( ) Work ( ) < -�"� 3 I Cell (
OWNER MAILING ADDRESS: CITY:� STATE: ZIP:
EMAIL
FAX _3S;(� ' 4
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
CITY:
STATE; ZIP EMAIL
PHONE #: Home (
Work (
Cell (
l ".�/
CONTRACTOR
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
How many buildings are located on this property?
Did you recently purchase this property ?� Yes (If yes give owner's name)
Is this a lot split? ® YES (Please bring copy of new legal description of property)
PROPOSED USE: . L k-T- ` iLt LZ2, y
(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 9y9n 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.
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Sign�at e 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 Safety Department
City of Rexburg
19 E Main
Rexburg, ID 83440
janellh@rexburg.org Phone: 208.359.3020 x326
www.rexburg.org Fax: 208.359.3024
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CITY O F
REXBURG
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Americas Family Community
NAME 1 �, k
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!! MECHANICAL
Mechanical Contractor's Name: S, Imo` Business Name:
Address City State
Cell Phone: ( )
Fax: ( )
Business Phone: ( )
Email
Mechanical Estimate $ <ne:) r (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES 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) (0 Oil Coal Fireplace Electric Hydronic
Zip
Mechanical Sizing Calculations must be submitted with Plans & Auulication
Point of Delivery must be shown on clans.
Signature of Licensed Contractor License number
Date