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Building Safety Department o FRVxB Rq
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City of Rexburg
19 E Main janellh@rexburg.org
Rexburg, ID 83440 www.rexburg.org
Phone: 208.359.3020 x326
Fax: 208.359.3024
OWNER'S NAME 6 W e- h 107 ( fOt4 /I l ot r
PROPERTY ADDRESS /I.!r; 10 I 6�-e, S -
SUBDIVISION
PHASE LOT BLOCK
C I T Y O F
REXBURG
America's Family Community
0700562
166 N 1st E- Couliard
Required f!l
ELECTRICAL
Electrical Contractor's Name �C �'w5 Z(c'dri C Business Name
Address 1-17 /ha 6 1 1`So vi 12•'ve r )06 yco( City ��1- I //s State Zip 0' y0
Cell Phone (21 7®f — x/9 Business Phone
Fax ( ) Email
Electrical Estimate ( cost of wiring & labor) $ (COMMERCIAL /MULTI - FAMILY ONLY)
TYPES OF INSTALLATION
(New Residential includes everything contained within the residential structure and attached garage at the same time)
Number of meters being installed
Up to 200 amp Service*
201 to 400 amp Service*
Over 400 amp Service*
Existing Residential (# of Branch Circuits)
Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year)
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
X Other Installations: Wiring not specifically covered by any of the above
Cost of Wiring & Labor: $ 2000 p°
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 Licensed Contractor License number y Date
The City of Rexbu rg's permit fee schedule is the same as required by the State o f Idabo
rel
CRY OF REXB URG
BUILDING PERMIT APPLICATION Please 0700574
19 E MAIN, REXBURG, ID. 83440 If the que; 166 N 1st E- Coullard Remodel
208 - 359 -3020 X326
PARCEL NUMBER: TD V= a �� W I C� U0 (we wm provide this tot you)
SUBDIVISION: N a UNIT# BLOCK # # ;_
(Addressing is based on the information - must be accurate)
CONTACT PHONE #
PROPERTY ADDRESS: 16 6
PHONE #: Home (2p8) ?5q g0(DR Work Pd) �4 C( & [ l 0 0 Cell (&8)
OWNER MAILING ADDRESS: 1 ( N f s� 1; CITY: > STATE: LD_ZIP:6
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 (
CONTRACTOR
MAILING ADDRESS:
PHONE #: Home (
EMAIL F.
MEN
Work ( ) Cell (
CITY:
IDAHO REGISTRATION # & EXP. DATE
How many buildings are located on this property? 2-
Did you recently purchase this property? Yes (If yes, list previous owner's name) ) + S?, onme✓,
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE: re. 1M med
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty 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 application or on the plans on which the permit or approval was
based. Permit &if not st ted within 18 , ays. Permit void if work stops for 180 days.
iO / Iq 1
Signature o Owne4!J DATE
Do you prefer to be contacted by fax, em PGPERMIT or phone? Circle One
WARNING — BUILD MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non - refundable and are paid in full at the time of application beginning Januaix 1, 2009.
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**
0
Build. ig Safety Department �FRtiXe�R�
-
City of Rexburg
s`► o
19 E. Main jonellh @rexburg.org Phone: 208.359.3020
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
CI'r Y OF
REXBURG
Americas Family Community
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
City
Address
State
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
20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Please complete the eltire Ap 0
NAME
PROPERTY ADDRESS
. , (� �-P' �` Permit#
SUBDIVISION
Dwelling Units:
SETBACKS
FRONT
Parcel Acres:
SIDE SIDE BACK
' �emodeUng UTBzuldindmg /Home (need Estimate $ r L t L
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Floor Area 1 E Unfinished Basement area `)
Second floor /loft area t�,rl Finished basement area
Third floor /loft area Garage area
Shed or Barn SG) Carport /Deck (30" ab��rade)Area
Water Meter Quantity:
* * * * * * * * * * * ** *Water Meter Size:
Required.!!)
PLUMBING
Plumbing Contractor's Name: � % , L- `fit ' Business Name.
Address ? n City 1
-� , — )t.�.� C State it Zip
Contact Phone: ouz �c; �� Business Phone: ( )
Email Fax
FIXTURE COUNT , (Mclud=roughed fixtures)
Clothes Washing Machine Sprinklers
Dishwasher 1 Tub /Showers
Floor Drain �_ Toilet /Urinal
Garbage Disposal Water Heater
Hot Tub /Spa Water Softener
Sinks (Lavatories, kitchens, bar, mop) C+ rwnp
Plumbing Estimate $ .�C' C' ,�� (COMMERCIAL /MULTI - FAMILY ONLY)
Signature of Licensed Contractor License Number& Expiration Date Date
The City of Kexburg's permit fee schedule i s the same as required by the State of Idabo
Please complete the entire •A Ap
on.
NAME
PROPERTY ADDRESS 16& M I S Permit#
SUBDIVISION �U
Requlredffl
MECHANICAL
Mechanical Contractor's Name 4C) M pw -d Business Name
Address
Cell Phone (
Fax ( )
Email
Mechanical Estimate $ (Commercial /Multi Family Only)
FIXTURES & APPLIANCES COUNT (Single Family Dwelling Only)
Furnace
Furnace /Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
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
Point of Delivery must be shown on plans
Signature of Licensed Contractor
The City of Rexburg 's
License number
schedule is the same as
the State
Date
City State Zip
Business Phone ( )
Exhaust or Vent Ducts
Dryer Vents
Range Hood Vents
Cook Stove Vents
i Bath Fan Vents
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
of ae,xapR0
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7
C I T Y O F
REXBU
_..___.___ nW _ ____.
Americas Family Community
OWNER'S NAME
PROPERTY ADDRESS
SUBDIVISION
PHASE
LOT BLOCK
r'
F HOME OWNER'S ELECTRICAL PERMIT
Honnener's Name
Address City State Zip
Cell Phone ( ) Home Phone ( )
Fax ( ) Email
TYPES OFINSTALLATION
(New Residential includes everything contained within the residential structure and attachedgarage 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)
Existing Residential (# of Branch Circuits)
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 Date
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho
Permit#
0 0
SUBCONTRACTOR LIST
Excavation & Earthwork: A - 6') o"
Masonry:
Roofing:
Insulation: Q,tA ljyl Q.,�
Drywall:
Painting: h`i.VV l_ &q Lk) Vl P.(
Floor
Coverings: LLVI Coo) L,('
Heating: _ h 014Aa -,, C d A94
Electrical: R i c� o-w k Luz V � U, 5
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor /Ceiling J
Siding /Exterior
0700574
166 N 1 st E- Couliard Remodel
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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 www.ibol.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
Cl 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
m/ 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 hereb"c rtify that the above information is true and correct to the best of my knowledge.
Date
(;�Lu Q- V\a
Print Name