HomeMy WebLinkAboutAPPLICATION - 19-00378 - 352 E 5th S - Addition - Garageo44Exavp�
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CITY OF
REXBURG
O
America's Family Community
BUILDING PERMIT FORM 102
Updated 1U/2U1G
BUILDING APPLICATION
Single Family Residence Remodel
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg. idahn R344n
For Office Use
Permit Number: JS Zoning: Application Fee Paid: ❑ $100
1. Proper Owner I
Name:,I�2r r>r�� Jccc,K or\
Address:�a —T S� C�. City: State: Zip Code: 93elfl b eA
Phone:
Email: C_<_C__ �<1 ,Pa
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?
JN Yes (Skip to #4 and complete the Homeowner's Exemption)
❑ No, I am working with the homeowner
2. Applicant I
Name: >,Q ei- 2^ �I �v� Role: (Owner, Tenant, Contractor, etc.)
Address: A G ,-� N City; }� v, State: _F_> Zip Code: R3 q -'1y
Phone: -20fg - X03 -8a-7p Email: f kS€-ys t' Z�,:4
Contact/Rep. Name: �' J
3. General Contractor
Name: �10 �—tee" on Registration #: Exp.:
Address: _ 1Z'a �S-I' S'� �;� City: State: 1_
�� Zip Code: !e_y b
Phone: I C)< -Y 03 8a -70_J I - I
Email: l c�Ga
Contact/Rep. Name: t- ea car K SQ Phone:ai::P3-yy3-1i�77o Email: _ i c-c.kson i"k,� I.
General Contractor Authorized Signature: Date: / `'
A copy ofyour state registration/license is require t e on file. If t i e first time you have done work in the City of Rex rg, lease provide
a photo copy ofyour license. If you are unsure ify ur license is on Ile, please check with the Permit Technician by calling (208) 372-2341.
4. Project Description
Address: s �p
Project Description: / c -r
• Estimated Tota Cost: $
•
Check All Included in Scope of Work:
M -K echanical Work Cost: $ 12'Electrical Work Cost: $ P Plumbing Work Cost: $
Note: Any contractors involved will n7No
fill out their respective application.
• Fireplace(s) Being Installed? El Yes
Building Permit fees for remodels are charged based on cost. The application fee applies toward the fee total. For details on how fees are
calculated, contact the Building Department. There will also be a plan review fee totaling 10% of the building permit fee.
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. 1 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.
Applicant's Name (print):&'46' e Signature: Date: 6 a
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection a sts called i a 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.o g Permit Technician - (208) 372.2341
OQ gEXBUgC
F� ro
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CITY O F
REXBURG
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Americas Family Community
Affidavit of Legal Interest
Building Safety Department
State of Idaho
County of Madison
I--1�
�Kms,+ � s
sa
Name Address
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. That I am the record owner of the property described on the attached, and I grant my permission to:
Lk
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 J a V) 4C— 20 j �1
Signat r "
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341 Revised 10, 2016
CITY O F
REXBURG
CW
America's Family Community
HOMEOWNER'S EXEMPTION
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
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 fill out this form showing your
exemption and send it with your permit application.
Idaho State Statute allows a homeowner to do work on their own residence:
An owner performing construction on the owner's personal residential real property, whether or not occupied by
the owner, provided however, this exemption shall not apply to an owner who is otherwise regulated by this chapter
who constructs a building, residence or other improvement on the owner's property with the intention and for the
purpose of promptly selling the improved property, unless the owner has continuously occupied the property as the
owner's primary residence for not less than twelve (12) months prior to the sale of such property;
Title 54, Chapter 52, Subsection C2)
I hereby certify that the above information is true and correct to the best of my knowledge.
Print Mme
Date/
Permit Technician - (208) 372.2341 www.rexburg.org Revised 10/2016