HomeMy WebLinkAboutAPPLICATION - 16-00046 - 525 S 2nd E - AT&T Tower Addition04 ¢T.tta Uqc
For ,sCITY OF
r
REXBURG
CIL
AmeNaus Family Community
35 N 1" E, REXBURG, ID
208-359-3020
Please Complete the Entire Application
If the question does not apply fill in NA for non applicable
16 -c-00`/6
PARCEL NUMBER: (We will provide this for you)
SUBDIVISION: UNIT# BLOCK# LOT#
VWN&K "AML+.• Z'/COW N 'RoCTLF CONTACT PHONE #
PROPERTY ADDRESS: S.Z5- -J'mlTH zA)Lo c1Z e k ogl q /p 83Y40
PHONE #: Home 1 Work Cell
OWNER MAILING ADDRESS: 2000 CO �rCITy:RSTATE:I�f�
EMAIL FAX
APPLICANT: (If other than owner) / r7L///tFJQ R/11AX7 Z --r- ZGryyl&W z:
(Applicant if other than owner, a statement authorizing applicant to act as agent for ner must accompany this application.)
APPLICANT INFORMATION: ADDRESS Aqs WDODIY4te CITY: r,9&r
STATE t0 ZIPIK36116
e7,9EMAIL �CD�f �c��kF Xfver�ei', c—vnP/
PHONE #: Home WorkL�2- -;&j Cell
CONTRACTOR: • a l- S,y\ L L C
MAILINGADDRESS: 3 -?J 3✓!d 5T Scru♦k CITY STATE --I Q ZIP—I.365/
PHONE: Cell# ;ZOY- 1?5-5 - 6(-/ 1 % Work# Fax
EMAIL�eeJ Wy3aliota� Ha � MLjDAH w IDAHO REGISTRATION # &EXP. DATE
How many buildings are located on this property?
Did you recently purchase this property?ZrNO ❑ YES
Of yes, list previous owner's name)
Is this a lot split? 0"'NO ❑ YES (Please bring copy of new legal description of property)
PROPOSED USE: ffVP1�A1A1,4P k"iRELESS Ccr
(i.e., Single Family Residence, Muld Family, Apartments, Remodel,
Addition, Etc)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: undcrpenalty, of pointy, I hereby certify that I
have read this application and state that the information herein is correct and 1 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. 1 agree to comply with all City regulations and State lams relating
to the subject matter of [his 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 miseepresenmtion of fact
in the application ans on tbepumtit ora t a^al was based. Permit void if not started within 180 days. Permit void ifavmk stops for 780 days.
__J 11 I (O
Signature of Owner/Ap nt DATE
Do you prefer to he c9ifinc y fax, email or phone?
?ERMIT MUST BE POSTED ON: CONSTRUCTION SITEI
am PaW. is luB at the pmt. ofaPPticarion beginnin97
ince fthe plan review he does not constitute plan p,..l
35N PE Business Application A;o4yueaRae C I TY OF
Rexburg, JD 83440 °,1 RT.,YnT Ti7f�1�1I
www.rexburg.org cW
America's Family Community
Phnne- 20&359.3020 Fax: 208359.3022 Hntline- 20R97993dd nr Tovh lnsnaclinncla)ravhurn nrn c
Please take the rime to answer all questions so that we can further assist you and your facl!!ry Thank You.
What type of business will be performed UA194# 640 6dr/&7, V ee1V4w1ekr1,*A15 tpaiwy
Will the business have food preparations?
Will there be any cooking of foods?
Will there be any deep fat frying?
Will you have food disposal on site?
Will there be any maintenance or mechanical work in the building?
Will there be sumps or floor drains in the facility?
Will the business require more parking?
Will the business have any chemicals on site?
Is this business occupying an existing building?
Will the business be doing any structural/or remodeling changes to the building?
Any changes to the electrical?
Any changes to the plumbing?
Is this business planned to be the same with different ownership?
Will there be a change of occupancy?
0 Yes O—No
Q Yes
G�No
Q Yes
("No
Q Yes
Q—No
Q Yes
G -No
® Yes
,0,No
Q Yes
42�—No
Q Yes
-Q-No
0 Yes
jo-No
_jC'Yes
0 No
Applicants SigpffCre__ Phone Date
I Certify that Tee uf�rmatron that I have provided above isto the best ojmy knowledge accurate and true.
Q Yes ONo
Q Yes ,Q,! No
0 Yes QrNo
0 Yes jeNo
5
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,
1Q Electrical Contractors/Journeyman,
2 Engineers/Surveyors;
2 Public Works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
95 Public Works Construction Management licensing Act (exempt from fee only registration required), or
5Q 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 perfom-iingmaintenance, 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
o Construction of a modular building (defined by Idaho Code) to be moved out of state
I hereby certify
ytthat
�the above information is true and correct to the best of my knowledge.
Signature Date'
Print Name
12