HomeMy WebLinkAboutAPPLICATIONS PT 2 - 07-00095 - City of Rexburg - Smith Park - Restrooms� 1 �
Building Safety Department
19 E. Mai*n
Rexburg, 18 3440
State of Idaho
County of Madison
I,
Name
City
jonellh@rexburg.org
www.rexburcj.ora
.1 %--f
City of Rexburg
Phone.- 208.359.3020 ext 326
Fc)x, 208.359-3024
Affidavit of Legal Interest
Being first duly SWOM upon oath, depose and say:
Address
State
(If Applicant is also Owner of Record, skip to B)
Nk�f 5 -R E ID
� 6 Loo
RE, X.BURG
America's Family Co";munity
A. That I am the record owner of the propexty described on the attached and I grant m
*
perrrassion to:
Name Address
to submit the accompanying application pertaining to that property.
B. agree to inciemni.fy, defend and hold Rexburg City d an its employees harmless. from any
claim ox liability resulting from any dispute as to the statements contam'ed herin ox as to the
ownership of the property which is the subject of the application.
Dated this day of 20
Si,gnatLire
Subscribed and sworn to before me the day and year first above written.
Notanr Public of Idaho
Residing at:
1 r sign Cxpires.
3
Please complete the, entire Application! If the question does n„t apply fiH in NA for non
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
qulred.fl.f MECHANICAL
Petrnit#
Mechanical Contractor's Name: Business Name:
Address
Q'tY..........State Tip
Contact Phone: Business Phone-, ( �
Email Fax
Mechankal estimate $
(Commercial/ Multi Family Only)
F1XTURES&APPLL4-NCES COUNT (Single Family Dwelling Only)
Furnace L,`xhaust or Vent Ducts
Furnace/Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorativ e gas-fired appliance
Incinerator System,
Boiler
Pool Heater
Fuel Gas Pipe outlets including stubbed in or future cutlets
Inlet Pressure (Meter Supply) PSI
Heat (0-rcle all that apply)
Mechanical. Sizi
Dryer Vents
Range Hood Vents
Cook Stove N7ents
Bath Fan Vents
other smear vents & ducts:
Gas Oil Baal Fireplace Elect -tic Hydronic
Calculations must be submitted with P12
Point of Delilllj��Viiry must be shown on n1ans.
Required! signature Licensed
Contractor
License number
Date
Th e C�l
&xburg',y of sperwitfee s u. s the same as requited b
the State of 10
_JkT
Li I--& !.T�_
5
Building Safety Department 4Ra
Rexbur
e 183440
laneith@rexburg.org
www.rexburg.org
City of Rexburg
Phone- 208.359.3020
Fax.- 208.359,3024
APPLICATION: "CONSTRUCTION PERMIT"
a
EY�6.BURG
I - Cw
Americas Family Community
CONSTRUCTION PERMIT #:
PERMIT APPROVED: YES/ NO $50-600 FEE PAID: YES/NO
APPROVED BY:
-APPLICANT INFORMATION:
Business Name,0
Office Address-.
city Scare Zip
Office Phone Number. ( )
Contractor Performing the Work:
Contact Person: Cell Phone # ( )
-LOCATION OF WORK TO BE DONE -
Street Address Where Work Will Be Done.,0
Business Name Where Work Will Be Done,,
Dates For 'work To Be Dane. To
Contact Person:
Phone Numben ( } Cell # � }
PLEASE CHECK THE TY -PE OF PERMITS), YOU ARE APPLYING FOR:
❑ AUTOMATIC FIRE -EXTINGUISHING SYSTEMS
❑ COMPRESSED GASES
,11 FIRE ALARM AND DETECTION SYSTEMS AND RL
EATED EQUIPMENT
❑ FIRE PUMPS AND RELATED EQUIPMENT
❑ FLAMMABLE AND COMMBUSTIBLE LIQUIDS
❑ HAZARDOUS MATERIALS
❑ INDUSTRIAL OVENS
D LP -GAS
PRIVATE FIR] C-4 HYDRANTS
❑ SPRAYING OR DIPPING
0 STANDPIPE SYSTEMS
1:1 TEMPORARY MEMBRANE STRUCTURES, TENTS, AND CANOPIES
Applicant -'s Signature Date
■ Room noun MENOMONEE 0 EMONNERE mamma NEWERNMEN RENDMENA NONE NEEN MENEM memos ■ ■
7
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete.
Masonry:
Roofing:
Insulation:
Drywall:
P-ainting:
Floor
Coverings:
Plumbing:
Hcating.-
Electrical:
SPecial Constriction
(Manufacturer or Supplier)
hoof Trusses:
Floor/Ceiling joists:
Siding/Extetior Trim:
Other:
�16,i
EXEMPTIONS FROM STATE REG1STRr�TION
As of January? 1, 2006, the City of Rexburg can no longer sell permits without havm'g a copy of your State
registration number or your exemption from the State �r
registrattc�n. 'lease send a copy of your state regist�ratior�
fill out this foam showing your exemption and send it with your license renewal or your next permit application.
(TMs hst is a summarization of Idaho Code Title 5.4 Chanter S?O S For f7,�� ,AAT1Y1i�-ir�r�c+ .-.�+1,
vvw-_ y
see the State's website at w.ir�;�
bnl_�hr-�_
oar
„� c,G mpuons please
cont.htrn)
❑ Cuirrently State licensed putsuant to Tide 54 Idaho Code, Chapters:
3 Architects,
10 Electrical Contractors /Journeyman,
1 � Eng4neers/i,�)urvevors,
0
u
0
0
a
X
0
19 Public works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
45 Public Works Construction Management Licensing Act (exempt from fee oily registration required), or
50 Installation of heating, ventilatzon and air conditioning systems
Employee or volunteer of a licensed conttactor or part of an educational curriculum ox nonprofit charitable
activity xvith no wages or Salary
Employee of a US Government agency (State, GO, Coun"-r, or other municibality)
Public Utility d
Ding construction,, maintenance, or development to its own business
Involved with has, oil or xnin.eral operations
Supplier doing no installation or fabricating
Contracting a ptoject or projects Nvlth a total cost less than $2000
operation of a farm or ranch or construction of agriculture buildings exempt from Idaho B-Lfflding Cede
Any type of water district operations
Warp in rural districts for fixe prevention purposes
o owner who performs work on own property or contracts with a rega.stezed cantractor to do work as Ionas
the property is not forresale tivith%n 12 months 9
El owner or lessee of comm.ercialpfopexty performing mairztena�cc, rep=, alte�at�.on �r construction on that
Property
❑ Read estate licensee/ptopetty, manager acting wi.thin Idaho Code
❑ Enga,W'ng in the logging industry-
Renter working on the property where they live with the property owners approval
❑ Construction of a bading used for industrial cherra-tcal processing per Idaho Code
o Construction of a modular building (defined by Idaho Code) to be moved out ref stag
I he-reby certify that the above infarrnation is true and correct to the best of My knowledge.
Signature
Prat dame
Date
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