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HomeMy WebLinkAboutAPPLICATION - 08-00590 - 1627 W 5500 S - MortensonCITY OF REXBURG - -- - -- MECHANICAL PERMIT APPLICATION Pleas 0800590 19 E MAIN, REXBURG, ID. 83440 If the qi le 208- 359 -3020 X326 ,-- ��( 1627 W 5500 S- Mortensen PARCEL NUMBER: ��_ _'_ � y � �- (�`'`t� _ SUBDIVISION: UNIT# BLOCK# LOT# (Addressing is based on the information - must be accurate) OWNER: 0/1; tie,._ CONTACT PHONE # PROPERTY ADDRESS: l6-2,7 I,ti,ey, 4!5cne, �( +V), PHONE #: Home ( ) �`1 Work ( ) Cell ( ) OWNER MAILING ADDRESS: /��(� J ` 1 CITY: 'W 1 L STATEN P EMAIL IM ( `I(-�. �n © 47 ( P 1— ZIP: 3 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 STA ZIP EMAIL PHONE #: Home ( ) Work ( ) CITY: Cell ( ) CONTRACTOR 6 .. ,.j cu_ 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 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 applicatSon 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. of / Z-- / 0 / 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 t .t 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 CITY OF UR Americ4 Family Community NAME PROPERTY ADDRESS SUBDIVISION MECHANICAL Mechanical Contractor's Name: t ry .rz',..L ° U'fr- 1`..,014 ­i Business Name: I L 1k f'G;�/ Wi l]u :rte x r el ti _ Address _ C.. r.�,� ..__ ... - City �_, E:1 State l N Zip 3Y Cell Phone: n 5 25 Business Phone: ( ) Fax: ( ) Email ' i�'�tris�.J i ��n��_ %��5;.� C 4�✓� Mechanical Estimate $ (Commercial/Multi. Family Only) FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only) Furnace Exhaust or Vent Ducts i Dryer Vents Required!!! Furnace /Air Conditioner Combo Heat Pump Air Conditioner Evaporative Cooler Unit Heater Space Heater Range Hood Vents Cook Stove Vents Permit# Bath Fan Vents other similar vents & ducts: !,, 4W W-1 rt— Z " Decorative gas -fired appliance Incinerator System Boiler Pool Heater 6 Fuel Gas Pipe Outlets including stubbed in or future outlets Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic Mechanical Sizing Calculations must be submitted with Plans & Application Point of Delivery must be shown on plans. n ,. 313 Z - 7 Signature of Licensed Contractor License number i Date The City of Rexburg's permit fee schedule is the same as required by the State of Idaho 11