HomeMy WebLinkAboutAPPLICATION - 06-00567 - City of Rexburg - Police Department - MechanicalCITY OF AEXBUAG
BUILDING PERMIT APPLICATION Me: 06 00567 in!
19 E MAIN, REXBURG, ID. 83440
208 - 359 -3020 X326 police Dept - Mechanical
PARCEL NUMBER:
SUBDIVISION: uNri BLOCK# LOT#
is based on the information - must be accurate
PROPERTY ADDRESS:
PHONE #: Home (
OWNER MAILING ADDRESS:
EMA
Work (
CONTACT PHONE #
Cell ( )
CITY: STATE: ZIP:
AX
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 FAX
PHONE #: Home (
Work (
Cell (
CONTRACTOR
MAILING ADDRESS: �� x 1''I CITY STATE .r ZIP $3,S�Q
PHONE: Cell#
EMAI Z IWo1;KS �tD.ti IDA�I r I0 REGISTRATION # & EXP. DATE T � - IVG— C— -2 /
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-0 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 ofperjur 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 a plication r on the plans on which thiA� or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
A
Si 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 Tanya 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 your check does not clear**
Please complete the en* Application! If the question doell, t apply fill in NA for non
apphcabl
NAME �,�.� ?�f� I j EPgi?T'M t -
PROPERTY ADDRESS Permit#
SUBDIVISION
RequiredLY
MECHANICAL
Mechanical Contractor's Name: V =Nc Business Name:
Address O arc I"( City E& Y State _Z7P Zip 3a7 y
Contact Phone: 3 S 7 - oZ I S/ - ) Business Phone: k? 3 ^ 7 — �• 3 5/ 7
Em Fax
Mechanical Estimate $ (Commercial /Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace 3 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
5 1_ other similar vents & ducts:
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric Hydronic
1W Tw El i" MEMO Me
Po o De must b e shown on p lans,
J
equiredl Signature of Licensed Contractor License number Date
The 0 0 of Rexburg's permit fee schedule is the same as required by the State of Idaho