HomeMy WebLinkAboutAPPLICATION - 08-00587 - 525 S 5th W - GossCITY 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)
PROPERTY ADDRESS:
.
sas
CONTACT PHONE # ;
s-
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 3 'l3fl L-F 2 y v 1V CITY: 1z ; !� Sy
STATE; _ ZIP 3 ` q l EMAIL FAX 7 V e-
PHONE #: Home ( ) Work Cell ( ) 31 - 7 - - 7( ) 2(
CONTRACTOR
MAILING ADDRESS:
PHONE: Home#
EMAIL
W.'"
How many buildings are located on this property?
CITY
Cell#
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 perjur 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 appliccatio or on the plans 9q which the permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
tgnature of wner /Applicant DATE
Work#
Cell ( )
STATE ZIP
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 jonellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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C I T Y OF
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America's Family Community
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: jz C L y 12 0 � �� Business Name:
Address °�.3 L' a �! v v City 3 t y S State Z J Zip �3 `I L6 Z
Cell Phone: (ao8) 3 t - 7 - 7 V at Business Phone: (Po8)
Fax: (' o $r) 7 115 • 7 3 S °i Email
Mechanical Estimate $ (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:
Z Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply) Ga. Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
__7� a
Sign a of Licensed Contractor
The City of Rexburg's
License number
schedule is the same as
1� r vy
Date
by the State of Idaho