HomeMy WebLinkAboutAPPLICATION - 08-00279 - Dormitory - Handicap RampsUQ Rexa[;R
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;� Please Complete the Entire Application!
If the question does not apply fill in NA for non annlirahL-
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' America's Family Community
MFD 08 00279
COMMERCIAL & MULTI FAMILY BUILDING P Handicap Ramps for
19 E MAIN, REXBURG, ID 83440
208 - 359 -3020 X326 Dormitory Housing
PARCEL NUMBER:
149E 2nd S &175 or179E 2nd S
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the info/mation - mu*f be accurate)
CONTACT PHONE #
PROPERTY ADDRESS:
PHONE #: Home ' Work ( ) Cell
OWNE MAILING DRESS: �bC�� CITY: 2` TATS >2ZIP:�
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EMAIL° �l FAX
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
PHONE #: Home (
RMAIL F
Work ( ) Cell (
CONTRACTOR
MAILING ADDRESS:
PHONE: Cell#
Work#
CITY STATE ZIP
Fax#
EMAIL IDAHO REGISTRATION # & EXP. DATE
How many buildings are located on this property? /
Did you recently purchase this property - No Yes (If yes, list previous owner's name) .
Is this a lot split? YES (Please bring copy of neyv legal description of property)
PROPOSED USE:
(i.e., Single Family Residence, Multi
Garage, Conlnercial, Addition, Etc.) — CIRCLE ONE
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalt of perjury, I hereb certif that I
have read this application and state that the tion 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 th ity C until 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 applicati and e uthorized representatives of the City to enter upon the above - mentioned property for inspections purposes. NOTE:
The building official may revoke a emut ap royal 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 n w ch the unit or approval was based. Pemut void if not started within 180 days. Permit void if work stops for 180 days.
Signature of Owner/ Applican DATE
Do you prefer to be con cte 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 Tangy L 201
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**
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Or
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Building Safety Department
City of Rexburg
19 E. Main jonellh @rexburg.org Phone: 208.359.3020 ext 326
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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America's Family Community
Affidavit of Legal Interest
State of Idaho
County of Madison
Name
City
Address
da -�d
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 herin or as to the
ownership of the property which is the subject of the application.
Dated this �� day of M oL lf t . ,20 0
Jlgll"aLUL
Subscribed and sworn to before me the day and year first above written.
t OTA* Notary Public of Idaho
• C • Residing at: �lti �d Ga 1�. I9
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' City of Rexburg
NAME
PROPERTY ADDRESS
SUBDIVISION
Dwelling Units:
Parcel Acres:
include the exterior wall
SETBACKS
FRONT SIDE SIDE BACK
Remodeling Your Building /Home (need Estimate $ 2 ,
SURFACE SQUARE
First Floor Area
Second floor /loft area
Third floor /loft area
Shed or Barn
Water Meter Quanti
Garage area z°
- arport /Deck (30" above era
* * * * * * * * * * * * * ** Water Meter Size:
I Please Complete the Entire Application! I
If the question does not apply fill in NA for non applicable
building)
Requited!!!
PL U 1V
Plumbing Contracto '
Contact Phone: ( )
G
Name: Business Name:
\ , City
Clothes Washing Machine
Dishwasher
Floor Zub/SP
I Garb
Hot T
Sinks
(Lavatories,
Sprinklers
_ Tub /Showers
Toilet /Urinal
ater Heater
Wate oftene
Plumbing Estimate,") �/` ` / (Commercial Only) N
r C 1 1 1 4 9 J /1 F
Req d! Signature #11censed Contractor License number Date
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