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Home My WebLink AboutAPPLICATIONS - 08-00047 - Madison Women's Clinic - Basement RemodelV�o p4xeUg� dx — C I TY O Fl ') 08 0004 / REXBLTIZG :Madison Women's Clinic XB Americas Family Community Basement Remodel COMMERCIAL & MULTI FAMILY BUILDING PERM1 a t11'ra at roll aya 19 E MAIN, REXBURG, ID 83440 208-359-3020 X326 PARCEL NUMBER:M��JCT) I�j (We will provide this for you) SUBDIVISION: UNIT# BLOCK# LOT# is Dasea on me mIormauon - must De Ih1'OL CONTACT PHONE # 3!;6-61K PROPERTY ADDRESS: IS Mc'd'S'- P-66 "r'4 04,,k PHONE #: Home ( Work ( ) 36(.' (185- Cell ( OWNER MAILING ADDRESS: CITY: STATE: ZIP: EMAIL FAX APPLICANT: (If other than owner) 14A d -ha V L 0S61Z- (Applicant if other than owner, a statement authorizing applicant td act as agent for owner must accompany this application.) APPLICANT INFORMATION: ADDRESS Ll el � w , � MI) W CITY: the STATE; -t-IJ ZIP Z1544o EMAIL Wcldc 2 U 3 of 60L FAX 3S4..S011 PHONE #: Home (-ZLO 36 �1 Y Work CONTRACTOR: C. Cell( ) 3'4b it MAILINGADDRESS: '45'ST Wt tl w CITY Pt -CL -1 STATE IU ZIP T PHONE: Cell# �rlo-131 Work# Fax# 35 & SS`s `i EMAIL IDAHO REGISTRATION # & EXP. DATE R(.T--3:sb'3 How many buildings are located on this property? Did you recently purchase thisproperty? Yes If es list previous owner's91: 6 w 6 u U a- ' 11111 Y YP � ( Y Is this a lot split? 0 YES (Please bring copy of new legal description of pr JAN 3 0 2008 PROPOSED USE: t VIi61.% V^'pJ- (i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage Co erci dditio Etc.) -- Q �1 ' I QI APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: 1 i VF, REXBURG 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 2003 International Code in cases of any false statement or misrepresentation of fact in the application or on the pImyk4+q a permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days. Ug I. z1 / o� Signature of 0xviter/Applicant DATE Do you prefer to be contacted by fax, email or phone? Circle One WARNING -BUILDING PERMIT MUST BE POSTED ON CONSTRUCTION SITEI Plan fees are non-rdundable and are paid in full at the time of application beginning lanuary i. 2055 City of Rexburg's Acceptance of the plan review fee does not constitute plan approval **Building Permit Fees are due at time ofapplication** **Building Permits are void if your check does not clears* Building Safety Department City of Rexburg 19 E. Main ionellh®rexburg.org Phone: 208.359.3020 ext 326 Rexburg, ID 83440 www.rexburg,org Fax: 208.359.3024 Affidavit of Legal Interest CITY OF nXBURG America's Family Comm, ..i y State of Idaho County of Madison nn I, 6 F"('Q C 13ci `-�oa , I5 /V�Qc� �_Sn�1 Yr Fes�p�4 Namc Address 4r City --�$ State Being fust 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 o$ attached, and I ant my permission to: av, q W, R Vw Yi, Name QAddress 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 r 20_ Q Signatttre Subscribed and sworn to before me the day and year first above written. t4 O TA 9 lN Notary Public of Idaho 22 �Am AUef C '� Residing at: _ a M commission expires: "n-l"ko 3 NAME fVlaulrp� l,�n�Qc.S C�t�r PROPERTY ADDRESS 15- SUBDIVISION Dwelling Units: Parcel Acres: City of Rexburg Please Complete the Entire Application! 1- If the question does not apply fill in NA for non applicable SETBACKS FRONT SIDE SIDE BACK o+ Remodeling Your Building/Home (need Estimate) $ 1 90t 0-" SURFACE SQUARE FOOTAGE. • (Shall include the exterior wall measurements of the building) First Floor Area Unfinished Basement area Second floor/loft area Finished basement area N 0c74 Third floor/loft area Garage area Shed or Water Meter Quantity: RequiredLY PLUMBING Dec~ vouo� above Water Meter Size: Plumbing Contractor's Name: pt± j PL6,K Business Name: - 1C.QALtj U Address City Contact Phone: ( ) Business Phone: ( FIXTURE COUNT (includingroughed fixtures) Clothes Washing Machine Dishwasher Floor Drain Garbage Disposal Hot Tub/Spa Sinks (Lavatories, kitchens, bar, mop) Plumbing Estimate $ (Commercial Only) Iooq <� Requiredl Signature of Licensed Contractor License number Sprinklers _ Tub/Showers Toilet/Urinal Water Heater Water Softener 21 aV�os Date 0 'l The City of fuxburg''s permit fee schedule is the same as required by the - Jte of Idaho NAME J 4Lk& u^ 1Jowe,3 PROPERTY ADDRESS l't SUBDIVISION Requiredffl Mechanical Contractor's Name: Please Complete the Entire Applicadonl If the question does not apply fill in NA for non applicable Permit# MECHANICAL Contact Phone: ( ) 3 r �T? ° Business Phone: ( Name: e1 ✓V° State �y' 7.in jdtfo Mechanical Estimate $ P"66D (Commercial/Multi Family Only) FIXTURES & APPLIANCES COUNT (Single Family Dwellmmg Only) Furnace Furnace/Air Conditioner Combo Heat Pump Air Conditioner Evaporative Cooler Unit Heater Space Heater Decorative gas-fired appliance Incinerator System Boiler Pool Heater Exhaust or Vent Ducts Dryer Vents Range Hood Vents Cook Stove Vents Bath Fan Vents other similar vents & ducts: Fuel Gas Pipe Outlets including stubbed in or future outlets Inlet Pressure (Meter Supply) PSI Heat (Circle all that apply) as Oil Coal Fireplace Electric Hydxonic Mechanical Sizing Calculations must be submitted with Plans & Application Point of Delivery must be shown on plans. og Requiredl Signature of Licensed Contractor License number Date The City of Rexburg s permit fee schedule is the same as required by the State of Idaho Building Safety Department City of Rexburg 19 E Main jonellh®rexburg.org Phone: 208.359.3020 x326 Rexburg, ID 83440 www.rexburg.org Fox: 208.359.3024 OWNER'S NAME ime-j or C/ -X"+ -IS CI u, PROPERTY ADDRESS YS Inn:0 ., Q11 VOIL SUBDIVISION PHASE RequiredMf LOT BLOCK ELECTRICAL Permit# CITY OF REX,,URG Americds Family Community r Electrical Contractor's Name KAJX a✓ 5 r -I-&^ Business Name 101 oS Address Pb. (3()1 7-L 1U&j'Ak -City---LJ q 0 )-6 State �PA zip C6343,G Cell Phone (ap&) l Business Phone Fax ( Electrical Estimate (cost of wiring & tabor) $ 1 3t 60V (COMMERCIAL/MULTI-FAMILY ONLY) TYPES OF INSTALLATION (New Residential includes everything contained within the residential structure and attached garage at the same time) Number of meters being installed Up to 200 amp Service* 201 to 400 amp Service* Over 400 amp Service* Existing Residential (# of Branch Circuits) LkV �-�FiSat� . set-ul� Temporary Construction Service, 200 amp or less, one location (for a period not to exceed 1 year) Spa, Hot Tub, Swimming Pool Electric Central Systems Heating and/or Cooling (when not part of a new residential construction permit and no additional wiring) Modular, Manufactured or Mobile Home Other Installations: Wiring not specifically covered by any of the above Cost of Wiring & Labor: $ Pumps (Domestic Water, Irrigation, Sewage) Requested Inspections (of existing wiring) Temporary Amusement/Industry *Includes a maximum of 3 inspections. Additional inspections charged at requested inspection rate of $40 per hour. (--�')Ig1( `,&, -2-T-013 0 Signature of Licensed Contractor License number Date The City of Rexburg'.r permit fee schedule is the same as required by the State of rdaha Building Safety Department OQ RR aVRG City of Rexburg o 19 E. Main jonellh@rexburg.org Phone: 208.359.3020 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 CITY OF REXBURG America's Family Community APPLICATION: "CONSTRUCTION PERMIT" CONSTRUCTION PERMIT #: PERMIT APPROVED: YES/ NO $50.00 FEE PAID: YES/NO Business Name: Office Address: Office Phone Number:(Z6`0 )_ Contractor Performing the Work: Contact Person: M Kr•nr APPROVED BY: SS`4 city s Street Address Where Work Will Be Done: Business Name Where Work Will Be Done: 1'li Dates For Work To Be Done: -2- 1 -A Contact Person: M6 PA- "hL14s- fL- Phone Number: (_) State Zip Cell Phone # ( ) 3cio- 1'131 r NIL 1 -JUNKS L-ltm,t To (,,_I-ot Cell # (_) - -;�O, � -i -13 PLEASE CHECK THE TYPE OF PERMIT(S) YOU ARE APPLYING FOR: ❑ AUTOMATIC FIRE -EXTINGUISHING SYSTEMS ❑ COMPRESSED GASES ❑ FIRE ALARM AND DETECTION SYSTEMS AND RELATED EQUIPMENT ❑ FIRE PUMPS AND RELATED EQUIPMENT ❑ FLAMMABLE AND COMMBUSTIBLE LIQUIDS ❑ HAZARDOUS MATERIALS ❑ INDUSTRIAL OVENS ❑ LP -GAS ❑ PRIVATE FIRE HYDRANTS ❑ SPRAYING OR DIPPING ❑ STANDPIPE SYSTEMS ❑ TEMPORARY MEMBRANE STRUCTURES, TENTS, AND CANOPIES Applicant's Signature Date ............................................................•.............................. 7 SUBCONTRACTOR LIST Excavation & Masonry: Insulation: P 14AC Wei Drywall: ��P S%at. st� Paintin o• V'vcdl/ �+�hn'aS Iia .✓/ ��i Floor Coverings:— Plumbing:— Heating: overings:Plumbing:Heating: Special Construction (Manufacturer or Supplier) Roof Floor/Ceiling Siding/Exterior 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, 10 Electrical Contractors/Journeyman, 12 Engineers/Surveyors, 19 Public Works Contractors (exempt from fee only registration required), 26 Plumbing/Plumbers, 45 Public Works Construction Management Licensing Act (exempt from fee only registration required), or 50 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) Cl 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 performing maintenance, 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 ❑ Construction of a modular building (defined by Idaho Code) to be moved out of state I hereby certify that the above information is true and correct to the best of my knowledge. Signature Print Name Date