HomeMy WebLinkAboutAPPLICATION - 07-00525 - 204 N 3rd E - FireplaceCITY OF REXBURG
MECHANICAL PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
PARCEL NUMBER: Q:Q(2 P Y1�.' In
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SUBDIVISIC)N: UNIT#
(Addressing is based on the information - must be accurate)
J! 0 WNER:
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PROPERTY ADDRESS:"
rtiuivN #: Home (:� ) Work
OWNER, MAILING ADDRESS:_),Nt ?>OD r.
EMAILf'hlAinivil ;tG7
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FAX
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BLOCK# LOT#
CONTACT PHONE #
Cell
STATE:
ZIP: I ,
APPL-ICANT-. (If other than owner}
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany thzs application.,)
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APPLICANT INr{]RMATION: ADDRESS
CITYE0
STATE; ZAP EMAIL .FAX
PHONE#: Home ( ) Work ( ) Cell ( �
CONTRACTOR
...
MAILING ADDRESS-
PT-40NE:
Flom& Work#
EMAIL FAX
How many buildings are located on this property?
Didyou recently purchase this property?(NbYes (If yes give owner's name)
Is this a lot split?(* YES (Please brine cony of now Io n ,aP�,.n...:,...
PROPOSED USE: t V-1
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v.G., 3111gie ramfly Kesidence,ulti Family, Apar tents, Remodel, Garage, Commercial, Additian, Etc.)
APPLICANT'S SIGNATURE
,5 CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that z 11ave
react this application and state that the infarrnation herein is correct and I swear that any information which may hercafter be given by me in hearings before the Manning
and Zox3rng Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply with all City regulations and Mate la��us relating to the
subject mattes of this applicafian and hereby authorized representatives of the City to enter upon the above-nnentianed property for inspections purposes. NATE: The
building official may revoke a permit on approval issued under the provisions of the 2003 InternationalCode in cases of any false statement or misrepresentation of fact in
tae application or on the plans on which the permit or approval was based.Permit void if not started within 180 days. Permit void if Wark stops for 180 days.
Signat 'r of Owner/Applicant �� � �' 1
Da yo prefer, to be contacted by fax, email or phone? Circle One DATE
WARNING — EUILAING PERMIT MUST BE POSTED ON CQNSTRLTCTIC]N SATE!
Pian fees are non-refundable and are paid in full at the time of application beginning Janua 1 2005.
City nfRexburg's Acceptance of the pian review dee does nit tonstiiafe plan approval
Building
Safety Department iaABR
19 E Man
Rexburg, ID 83440
NAME �J��
PROPERTY
SUBDIVISION
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Www.rex, urg,org
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City of Rexburg
Phone: 208.3,59.3020 x326
Fox: 208.3 9.30.2 -Ar
Required!!! MECHANICAL
Permit#
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Mechanical Contractox's Name: Business Name:
Address City —State
Zip
Cell Phone-. Business Phone
Fax Email
Mechanical Estimate S (CommerciaUMulti Family Only)
FIXTURES &APPLIANCES c
Furnace
FurnacelA,ir Conditioner Combo
Heat Pump
Air Conditioner
----------- -Evaporative Cooler
Unit Heater
Space Heater
Decorative gas-fired appliance
Incinerator System
Boiler
Pool Heater
(Single Family Dwelling Onl3'l
Exhaust or Vent Ducts
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & duets-.
Fuel Gas Pipe Outlets including stubbed in or future outlets
Heat (Circle all that apply)
Gas Oil Coal Fireplace Electric Hydronic
.6
Mechanical Sizin2 Calculations must be submitted with Plans & A
Point of Delivery must be shown on Plans,,
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Signature of Licensed Contractor -
The C
License number
ty ofRexburg -s permitfee schedule is the same as required by the State
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