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CITY OF KEXB UKG —
BUILDING PERMIT APPLICATION Please co ' -- --'' --i ---f
19 E MAIN, REXBURG, ID. 83440 If the questioi 0700385
208 - 359 -3020 X326 782 Nina- Basement Remodel
PARCEL NUMBERJ P SMLI ( � - D (We will provide this for you)
SUBDIVISION: K( , S I UNIT# BLOCK# LOT#
(Addressing is based on the information - must be accurate)
Y- L C V I—,
PROPERTY ADDRESS: D i , 'v i?
PHONE #: Home ( ) Work (
Cell( ) - 7 0 %�
OWNER MAILING ADDRESS: CITY: STATE: ZIP:
EMAIL FAX 307 -Co I - 7 2
AP CANT (If other than owner)
(Applicant ther than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT INMATION: ADDRESS
STA
PHONE #: Home (
CITY:
EMAIL F
Work (
Cell (
MAILING
PHONE #: Home
Work (
PERMIT # —'
CONTACT PHONE #
CITY
Cell (
ATE ZIP.
IDAHO REGISTRATION # & EXP. DATE
How many buildings are located on this property? 6 N
Did you recently purchase this property? f4 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,
Commercial, Addition, Etc.) ��� ni: --��
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under p "nalty of perjury, e� 4 a
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 application or on the plans on which the permit or approval was
based. Pe it void if not started within 180 days. Permit void if work stops for 180 days.
V i lz _�L - 0 7/ 3
Signature of Owner /Applicant DATE
Do you prefer to be contacted by fax, email or ph oneircle One
WARNING - BUILDING Ph] IMT M T BE POSTED ON CONSTRUCTION SITE!
Plan fees are non - refundable and are paid in full at the time of application beginning Ianuary 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**
_}
Bull
Safety Department*
City of Rexburg
19 E. Main
Rexburg, ID 83440
ionellh@rexburg.org Phone: 208.359.3020
www.rexburg.org Fax: 208.359.3024
4 �
C I T Y O F
RE XBURG
America's Family Community
Affidavit of Legal Interest
State of Idaho
County of Madison
Name Address
City
Being first duly sworn upon oath, depose and say:
ZcbJ. �
State
(If Applicant is also Owner of Record, skip to B)
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 :T�-J�-, — '20 QJ
1
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Floor Drain I Toilet /Urinal
Please complete the etire Application!
NAME -,--
PROPERTY ADDRESS il- Permit#
SUBDIVISION VICES cJ vv a
Dwelling Units: Parcel Acres:
SETBACKS
FRONT SIDE SIDE
Remodeling Your Building /Home (need Estimate $ 15
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area Unfinished Basement are:
Second floor /loft area Finished basement area_
Third floor /loft area Garage area
Shed or Barn Carport /Deck (30" above
Water Meter Quantity:
* * * * * * * * * * * ** *Water Meter Size:
Required!ff
PLUMBING V
Plumbing Contractor's Name: � �CAKr- Stw- Business Name:
Address - 79 Z N) l - 0�i v City State Zip
Contact Phone: (xt - 70 r A '5GJ Business Phone: (U() ?J:3 -01'72
Email
FIXTURE COUNT (inclup%Wroughed fixtures,
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub /Spa
I- Sinks (L avatorie s, kitchens, bar, mop)
F
Sprinklers
T*S_howers
T oilet / Urinal
Water Heater
Water Softener
Plumbing Estimate $ (COMMERCIAL /MULTI - FAMILY ONLY)
L6�41�- Oujyv��,
Signature of Licensed Contractor
The
License Number& Expiration Date
schedule is the ,came as required by the State
(3 0
Date
Building Safety Department CITY OF
City of Rexburg
° REXBURG
19 E Main ionellh@rexburg.org Phone: 208.359.3020 x326 �. Americ4 Family
ily Comunity
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
OWNER'S NAME 1
PROPERTY ADDRESS M `Z N � rck l t4 ye Permit#
SUBDIVISION P I'LKS I
PHASE LOT BLOCK
HOME OWNER'S ELECTRICAL PERMIT
Home Owner's Name
Address - 72Z 4 V Y,t h 1 if r' City J State Zip �4 0
Cell Phone (2X)G) _70 -; G 2 Home Phone ( 3 4-1
Fax (20j) r I (ol Email
TYPES OF INSTALLATION
(New Residential includes everything contained within the residential structure and attached garage at the same time)
For power supplier requirements visit www.rockymtnpower.net
�'— Number of meters being installed
Up to 200 amp Service*
201 to 400 amp Service*
Over 400 amp Service*
Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year)
'C7 _ Existing Residential (# of Branch Circuits) - 4�frQ a )r 9 ASa
Spa, Hot Tub, Swimming Pool
Electric Central Systems Heating and /or Cooling (when not part of a new residential construction permit
and no additional wiring)
Modular, Manufactured or Mobile Home
Other Installations: Wiring not specifically covered by any of the above
Cost of Wiring & Labor: $
Pumps (Domestic Water, Irrigation, Sewage)
Requested Inspections (of existing wiring)
Temporary Amusement /Industry
*Includes a maximum of 3 inspections. Additional inspections charged at requested inspection rate of $40 per hour.
Signature of Home Owner
The
schedule is the same as
Date
the State
07 003
782 Nina-Basement Remodel
qp
One Window In C-leeping Rooms 0.5' c C!�
To Meet Egress Requirement
Of The 2000 IRC
Check With Supplier
(,) ' ^, Ad &J -5 Es 6
ROOM
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6D
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Roan:
71L 6.00in. X 11 ft 9.001►.
5ft 1.72in. X
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11, 6"x70"
Room
IT 6"x T 6'
N Landing
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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 www1bol.idaho.gov /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 certify that the above information is true and correct to the best of my knowledge.
a
1 �it
` Signature
V IC
�, Y J,
Print Name
0 "7
Date