HomeMy WebLinkAboutAPPLICATION - 08-00588 - 795 W Poleline Rd - Seely• CITY OF REXBURG 0
PERMIT # 44
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: I VL1 i e t L , ( CONTACT PHONE 3 y Z
PROPERTY ADDRESS: "7 S �,` �U I I t� ✓1
PHONE #: Home ( )
Cell ( )
OWNER MAILING ADDRESS: 29t; i-0, :JL1 l W-T Y: STATE:_I_DZIP: S W O
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
STATE; ZIP
PHONE #: Home ( )
Work (
CITY:
Cell ( )
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? 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 penalt 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 he 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.
� / 0? /�L
Signature of wne Applicant DATE
Work (
EMAIL
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
I e
• o �aexeu Rr
� � CITY Of
REXB
America's Family Community
NAME
PROPERTY ADDRESS
SUBDIVISION
Zip
Required!!!
MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City State
Cell Phone: ( )
Fax: ( )
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
Business Phone: ( )
Email
Permit#
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
Furnace / Exhaust or Vent Ducts
Furnace /Air Conditioner Combo Dryer Vents
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
v" Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
other similar vents & ducts:
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.
#0MM
Signature of Licensed Contractor
License number
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
Date
1 1 The City of Rexburg's permit fee schedule is the same as required by the State of Idaho