HomeMy WebLinkAboutAFFADAVIT - 17-00706 - 50 College Ave - The Avenues - ChandeliersCITY OF
REXBURG
cm,
America's Family Community
Affidavit of Legal Interest
Building Safety Department
State of Idaho
County of Madison
4 (—J 6N ev0L 6o, (7(4 L��P Qu2
Name Address
V
City State
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
A.T at 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 0*— day of 20—[1—
if
Signature
Subscribed and sworn to before me the day and year first above written.
�blic of Idaho v V
�OTARy C
W'. i Residing at:
PUBOCO S I
My commission expires:
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised 10, 2016