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Building Safety Department
City of Rexburg
19 E Main ionellh@rexburg.org Phone: 208.359.3020 x326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
OF µEXBURC
by f0
U 90
CITY OF
.RE.XBURG
America's Family Community
OWNER'S NAME
PROPERTY ADDRESS
SUBDIVISION
PHASE
LOT BLOCK
Permit#
4 -9 o
Required ffl ELECTRICAL
Electrical Contractor's Name s 11/ ( C C 4f siness Name c 4Zt (A
Address V42 Al City � State ,LQ_
Cell Phone -,7 7 Business Phone �) 6 7
Fax ( ) Email a 5P r - vt c.2 -e /e c Xv C
Electrical Estimate ( cost of wiring & labor) $ (COMMERCIAL ONLY)
(Includes the cost of materials installed regardless of the part' supplying it).
TYPES OF INSTALLATION
(New Residential includes everything contained within the residential structure and attached garage at the same time)
RESIDENTIAL ONLY
*Up to 1,500 sq ft - $72 ❑ *1,501 to 2,500 sq ft - $120
❑ *2,501 to 3,500 sq ft - $168 ❑ *3,501 to 4,500 sq ft - $216
❑ * *Over 4,500 sq ft - $216 plus $.04 /sq ft: sq ft total
;k Existing Residential (# of Branch Circuits) - $40 plus $10 per circuit: # of circuits
❑ Multi - Family Only: # of units per building - $120 /bldg + $60 /unit
❑ Services: Alterations /Repairs that require utility disconnection. (Estimate applicable for commercial).
❑ Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year) - $40
❑ Spa, Hot Tub, Swimming Pool - $40 plus $40 grounding grid where applicable
❑ Electric Central Systems Heating and /or Cooling (vhen not part of a nesv residential construction permit
and no additional wiring) - $40
❑ Modular, Manufactured or Mobile Home - $50 plus $10 per circuit
❑ Other Installations: Wiring not specifically covered by any of the above:
Cost of Wiring & Labor ,l (Includes the cost of materials installed regardless of the party supplying it).
El Pumps (Domestic Water, Irrigation, Sewage): horse power
❑ Requested Inspections (of existing wiring) - $40 /hr (1 hr minimum) plus $40 /hr thereafter
❑ Temporary Amusement /Industry - $40 plus $10 per ride, concession or generator
*Includes a maximum of 3 inspections. Additional inspections charged at requested inspection rate of $40 per hour.
** Includes a maximum of 4 inspections. Additional inspections charged at requested inspection rate of $40 per hour.
Contractor License number ate
Please complete the en Application!
If,the question does not apply fill in NA for non applicable
NAME J. -9VCty) N e l SCM
PROPERTY AD15RESS 1 '-� I R; rc K koertu.e Permit#
SUBDIVISION Mod ; - & f,' ,, j?lc&
Dwelling Units:
(TACK� 1 �r
FRONT
Parcel Acres:
SIDE SIDE BACK tt)
Remodeling Your Building/Home (need E stimat e) $ & I d r� � u
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
M Floor Area �)q , �� r
Second floor /loft area
Third floor /loft area
Shed or Barn
Unfinished Basement area
Finished basement area S S q
Garage area
Carport/Deck (30" above grade)Area
Water Meter Quantity:
* * * * * * * * * * * * ** Water Meter Size:
Required!!!
PLUMBING i l-,'v w � ) Plumbing Contractor's Name: Business Name: �F 6u,�d_ /� ie g 17
Address City &,< State Zip
Contact Phone: Business Phone: ( ) - 6
Email
FIXTURE COUNT (including roughed fixtures)
E; Clothes Washing Machine
r' Dishwasher
Floor Drain
Garbage Disposal
Hot Tub /Spa
✓ Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $
Fax
(Commercial Only)
Sprinklers
Tub /Showers
Toilet/Urinal
Water Heater
Water Softener
Signature of Licensed Contractor License number
The City of Rexburg's permit fee schedule is the same as
the State of Idaho
CITY OFREXBURG * OW0430
BUILDING PERMIT APPLICATION Pleas 171 Birch Ave - Addition 1 �
19 E MAIN, REXBURG, ID. 83440 If the q de
208 - 359 -3020 X322 n
PARCEL NUMBER: VPQ We will provide this for you)
i 4 r'"n{
SUBDIVISION: VCw(v `�'� t; k t(,A Ca, P� v-t" UNIT# `' BLOCK # _ LOT#
(Addressing is based on the information - must be accurate)
OWNER NAME: J . j 'X►Gty\ N'�etSon CONTACT PHONE - 742ci ICA 3
PROPERTY ADDRESS �J (ZC - ICI AVenLu /St Yee 1
PHONE #: Home (u� ) '" Z�1 Work (z&C) 4 (o q 1(Q Cell (ZO 3 J-3 " Q!� J
OWNER MAILING ADDRESS: S,*nf A 4&Q e - CITY:
EMAIL N1'Q1�0r\ - f qZq 0w6a,0o /A a
STATE: ZIP:
APPLICANT (If other than owner)_
(Applicant if other than owner, a statement
APPLICANT INFORMATION: ADDRESS
STATE; ZIP EMAIL
PHONE #: Home ( )
to act as agent for owner must accompany this application.)
Work ( )
CONTRACTOR
MAILING ADDRESS: , CITY
PHONE: Home#
EMAIL
Work#
Cell#
CITY:
FAX
Cell ( )
STATE ZIP
0A rvis*&O
How many buildings are located on this property? lJo use c -<{ a air d e
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: t I r dent
(i.e., Single Family Residence, MW10amily, Apartmehts, Re odel, Garage, Commercia
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATl Und naf perjury, p1b ertify
that I have read this application and state that the information herein is correct and I swear that an info atiot�chk her y me
in hearings before the Planning and Zoning Commission or the City Council for the City of Rexb rg sha be truthful and correct. I mply
with all City regulations and State laws relating to the subject matter of this application and here a tatives of the ter
upon the above - mentioned property for inspections purposes. NOTE: The building official may ev� p t
provisions of the 2000 International Code in cases of any false statement or misrepresentation of ac
permit or apJ1Tval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
-?0 /f /
*ure Owner /Applicant DATE
you prefer to be contacted by fix, 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 Permit Fees are due at time of application" "Building Permits are void if you check does not clear"
the
Please complete the entire Application! If the question does not apply fill in NA for non
applicable
NAME -VIV-
PROPERTY ADDRESS 19k R,gzc , J'�LQ Q- Permit#
SUBDIVISION
RequiredMf
MECHANICAL
r i �, rr�s
Mechanical Contractor's Name: X� `ire I b i �1 y 4 Kusmess Name:
Address P•Q. fi ZS City CeX"k`l State - Ca • Zip
Contact Phone: ( ) 35'T Business Phone: ( )
Email Fax 8� 7
Mechanical Estimate $ (Commercial /Multi Family Only)
FIXTURES & APPLIANCES 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
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Pool Heater
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) 1 Gas Oil Coal Fireplace Electric Hydronic
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
la"i a? WC-c- 44
Signatur o icensed Contractor License number
The City of Rexburg's permit fee sche is the same as
Date
the State of Idaho
5
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described on the attached, and I grant my
permission to:
Name Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any
claim or liability resulting from any dispute as to the statements contained herein or as to
the ownership of the property which is the subject of the application.
Dated this day of 9 20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
SUBCONTRACTOR LIST
Excavation & Earthwork:
WO-,TCk
Concrete:
Masonry:
Roofing:
Insulation:
Drywa A, tal,'6(',
Painting:
Floor
Coverings: tic ,S �(f
Plumbin s c RQ i
Heating:
r' I
Electrical: uwk 1)0,r � r fied
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists:
Siding/Exterior Trim:
Other:
EXEMPTIONS FROM STATE REGISTRATION
As of January 1, 2006, the City of Rexburg can no longer sell permits without having a copy of your state
registration number or your exemption from the State registration. Please send a copy of your state
registration or fill out this form showing your exemption and send it with your license renewal or your
next permit application.
(This list is a summarization of Idaho Code Title 54 Chapter 5205, for full definitions of these exemptions
please see the State's website at www.ibol.idaho.aov /cont.htm
❑ Currently State licensed pursuant to Title 54 Idaho Code, Chapters:
3 Architects,
10 Electrical Contractors /Journeyman,
12 Engineers /Surveyors,
19 Public Works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
45 Public Works Construction Management Licensing Act (exempt from fee only registration
required), or
50 Installation of heating, ventilation and air conditioning systems
❑ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit
charitable activity with no wages or salary
❑ Employee of a US Government agency (State, City, County, or other municipality)
❑ Public Utility doing construction, maintenance, or development to its own business
❑ Involved with gas, oil or mineral operations
❑ Supplier doing no installation or fabricating
❑ Contracting a project or projects with a total cost less than $2000
❑ Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building
Code
❑ Any type of water district operations
Work in rural districts for fire prevention purposes
Owner who performs work on own property or contracts with a registered contractor to do work as
long as the property is not for resale within 12 months
❑ Owner or lessee of commercial property performing maintenance, repair, alteration or construction
on that property
❑ Real estate licensee /property manager acting within Idaho Code
❑ Engaging in the logging industry
❑ Renter working on the property where they live with the property owners approval
❑ Construction of a building used for industrial chemical processing per Idaho Code
❑ Construction of a modular building (defined by Idaho Code) to be moved out of state
I hereby certi fy that the above information is true and correct to the best of my knowledge.
Sign a Da e
A,
� 9
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