HomeMy WebLinkAboutAPPLICATION - 16-00678 - 1038 Widdison Ln - ShopCITY OF
REXBURG
America's Family Community
i
BUILDING APPLICATION
Single Family Residence
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
Permit Number: IG'00�7� Deposit Amount: Cl $500 New Const. El $100 Addition or Remodel
1. Property Owner
Name:�0�l�1
AddreIQC K�3 State: 3�O Zip Code: IP 2'e �(D
Phone: 20d'-Z!�-r'r- i"9D(o Email: y -F larc ,orc}
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
'l Yes (Skip to #4 and complete the Homeowner's Exemption) ❑ No, I am a contractor working for the homeowner
2. Applicant _
Name: C� I h r i C (< SBti Role: (Owner, Tenant, Contractor, etc.) QI ✓ 29 v
Address:_�-tia City: State: Zip Code:
Phone: 2v,f -Lo I - S7 Email:
Contact/Rep. Name:
3. General Contractor
Name: Registration #: Exp.:
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
General Contractor Authorized Signature;) Date:
NOTE: Any sub -contractors involved will need to submit their own signed applications.
4. Project Description
Address: 10 ,q -OR- Lot #: Block #: Subdivision:
Check one: ) ,New Construction ❑ Addition ❑ Remodel
Project Description # of Water Meters: OA Water Meter Size:
Square Feet: Building Total:) -,9-1)0 sq. ft. Main Floor: sq. ft. Additional Floors: sq. ft.
Basement: . Cl Finished ❑ Unfinished sq. ft.
Garage sq. ft. Estimated Total Cost: $
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 2012
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 void if not
started within 180 days. Permit void if work stops for 180 days.
J
Applicant's Name (print): l_ 0 l \ -\ E r 1 C _ Ksonsignature: 2 `�� f "-J Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (288) 3 72.2 344 www.rexburg.org Permit Technician - (208) 372.2341