HomeMy WebLinkAboutAPPLICATION - 06-00399 - 647 Palmer Cir - New SFRCITY OF REXB UR G
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
PARCEf,NUMBER.-
SUBDIVISION.4
(Addressing is based on the i
OWNER NAME:
PROPERTY ADDRESS:
ores
�� I
PFRMIT #
PleaseiF *hn � .W.� #
If the ques
UNI -177-r
on
- rrtust be accurate)
PHONE #-Home (� _ 7 W
OWNER MAILING ADDRESS:
EMAIL
647 Palmer Cir
CONTACT PHONE 4oeiTzt__7� 7�_
It
ork ( ) Cell ( )
TP.
CITY.-,4aX
.1 --STATE.2�4_zlp: Vo
FAX
APPLICANT (If other than owner)
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner must accompany this application.)
APPLICANT fNFORMATION: AD
DRE03 CII'Y:
STATE; QIP EMAIL FAX
PHONE #-Home ( } Work ( ) Cell ( )
CONTRACTOR:
MAILING ADDRESS: CITY STATE ZIP
Du/1Tn� .u. rr_
rnvii, n +r: Home � � Work ( ) Cell ( )
EMAIL FAX IDAHO REGISTRATION # & EXP. DATE
How many buildings are located on this property?,_ �,.,d,
Did you recently purchase this propei-ty.yes (If yes give owner's name)
Is this a lot split? � yES (Please bring copy of new legal description of property)
PROPOSED USE:
(i.e., Single Family Reside
nee, multi Family^partments, Rem
It
t
1, Garfage, Commercial, Additions Etc.
APPLICANT'S SIGNATURE1 CERTIFICATION AND AUTHORIZATION:
that vthis fitstate��
that the information herein correct and I swear that x nfon ti
rY hearings forthe �'1�ni� �� ire � ` �� which .` 1��-e����r � in �
t � � � ��� x t� i Council � ilii i � �' � �� .� �!1 truthful. r��dcorrect, with all �� �`�lti� � �� �� r�.ti�. tthe, subject t��i I t ��1
atter f this app] is ation td hereby authorized representatives
f
rpr nt tives of the Cit
to enterion the above-mentioned property for inspections purposes. OTE: �� ��i�r��i�.� re under the.
ons of the 2003 Internationai Code in cases of any false st-citemcnt or misrepresei Ino Ct h provis
n e
rinit r a w
o which the not within 1d . P rmlt�l'd
1mo s
ZOO
SignatureOwe. r is
Do you prefer to be contted faxC}
DA E
axe r h ircle One
WARNING — BUILDING PERMIT MUST BE POST ON C
Plan fees are non-refundaMe and are paid in full at the time o' a P1
City of Rexbu.rg's Acceptance of the plan review fee doe n
o ovar
'Building Permit Fees are due at time of application** **Building Perm'its ars void If your check does notEr"
91
Please complete the entire APPI'1*cation!
NAME
PROPExrYAL
SUBDIVISION
i 1
If the question ones not apply fill in NA for non applicable
Dwelling _Units..0
I m7 1�1
.A
Parcel Acres:
Permit#
SETBACKS
FRONT ,35! � SIDE— 4or SIDE_/ BAC,K_3/
Remodeling Your Building/Home (need Estimate) $
SURFACE SQUARE FOOTAGE: (Shall include the exterior wall measurements of the building)
First Flo -or Area
Second floor/loft area
Third floor/loft area
Shed or Barn
Water Meter Quantity:
Required!!!
PLUMBING
Plumbing Contractor"'s Name;
roij
Unfinished Basement area
opm-
Finished basement. area �.
Garage area 7qo
Carport/Deck (30r"' a owe grade Area
Water Meter Sm*e,0
Business Name:
Address City State Ximp
Contact Phone: Business Phone; � )
Email Fax
FIX TURE CO UNT (in e lu-din.rou 6a, h e a f txtures
� .Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, map)
Plumbing Estimate $ 1 (Commercial Only)
..`� Sprinklers
�.41 Tub./Showers
Toilet/Uriwnal
Water Heater
/ Water Softener
Sicrnature of Lice
nsed
Contractor License number Date
The Cily , Rexburg s i � -
4 same i the State of1daho
Seo. 18. 2009 2'.36PM First Call j ew ei
Building Safely Department
�MOO
Rexburg, ID 6344()
, M .
WSPA ;,man -4
jclj') L3 fl�', QfeXb Lj rg. org
City of Rexburg
Phoma,- t;
12
Fox: 208.359.3024
1 lu
r
A
C 1 "lC Y da F
rzcvrrx l Y AllllKN,Sj , /�41 4*'I-;�,(hie%� l�iiUt� Pez[nit# 0
3
SUBDTVXSION
IUMM. �,q
1�I'U64kf6m�m&wp ..` '41�4�d4
ReqE
utred.
Mech
anicaZ Contractoorr7� a�e, BuSiness Name:
Address Y/0 j//G
Cell Ph
zips�
]Business Phone:��2 "�'7`"]�
� Email
Mechanical Estjxnate $0'
(CommerciaYMulti Family Only)
FIXT7ES c� APPLIANCES COUNT {'San,�Ze �a�n��y D�veldi�tg only)_ Furnace � Exhaust or Vent Ducts
Furnace/Ajr Conditioner Combo
Heat Pump
—� Air Conditibner
Evaporative Cooler
Unit heater
Space Heater
0
Decorative has -fired appliance
�...,� Incinerator systern
Boiler
��!•Pr,TY��I� �� Fool Heater
Myer Vents
Rangc Hood. Vents
Cook Stove Vents
s
Bath fan Vents
�.`. othev similar vends & ducts:
duel Gas PiPe-OUtlets includi-na tubbed �r1 Qr future Outlets
Heat (Circle, all that apply) Gas Oil Coal Fireplace Electfic Hydronic
Mechanical S
Izi Calculations must be submitted wl
POl'IIt Of Defirvery mytirt I in c►,...�,..
9 �
�
1
4M
lgnature of Liceiised Contractir
-- +� �IA�V Yt 11 VLi
License number
k
ffiIanPs & A
Tans.
Dat�
The 0feeadule i
��'—'�'�7v,e�^�rJ�1F�:�E, 7�a■,��':....'�"��]�aQrna��ii�.,�tE
"! 4�TF��17E3'Rti1�GF I�1�1 f
Iication
Please complete the ent Application! If the question doef,` "A apply fill in NA for non
applicable
0
NAME
PROPERTY ADDRESS
SUBDNISION
'—J
i,- e�-1 F
C&
Permi
"06 00399
Required.!! N� ELECTRICAL- No�u�r�
Electrical Contractor's Name Business Name
Address City State,
Cell Phone ( )
Business Phone ( }
Fax
( ) Email
Electrical Estimate (post of wiring & labor) $ (Commercial/Multi Family only)
Zip -
TYPES OF 11VS TALLA TION -RESIDENTIAL
(New Residential includes everything contained within the residential structure and attached garage at the same tirxxe)
Up to 204 amp Service*
201 to 400 amp Service*
Over 400 amp Service*
existing Residential (# of Branch Circuits)
>< Tempo-rary Construction Service, 200 amp or less, one location (for a period not to exceed 1 Near)
Spa, Hat Tui, Swimming Pool
Electric Central Systems Heating and- /or Coaling (when not past 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
dost of Wiring & Labor: $
Pumps (Domestic Water, Irrigation, Scwage)
Requested Ins pections (of existing xviring}
Temporary Amusement/Indusrnr
�Indudes a maximum of 3 inspections. Additional i11 ct1 11 hanged at requested ' .t n rate of per 1- ur.
Signature of Licensed Cont -r -actor
License number
6 of 1,?�e's rm�' t schedules � same �� required y S.
IN
i'
iio
ion! it the question does not appy fill .n Na ror nonPlease complete the entire Applicat
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Required!!!
F
MECHANICAL
Permit#
Mechanical CName. Busi Nrane
Address City________State
Contact Phone: ( Business Phone-. ( }
Email
Fay
Mechanical Estimate $ (CommerciaVMulti Family only)
FIXTURES & APPLIANCES COUNT (Siegle Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace/Air Conditioner Combo -3 5 �_ Dryer dents 1�;
Heat pump range Hood Vents
Aix Conditioner Cook Steve Vents
Evaporative Cooler � Bath. Fan Vents 70
Unit Healer other similar vents & ducts:
Space Heater
Decorative gas-fired appliance 15r � [�
Inc 1*nerator System
Boiler
Pool Heater
Fuel Gas Pipe cutlets including stubbed in or future outlets f��'
inlet Pressure (Meter Supply) PSS
I feat (Circle all that apply) Gas 01H Coal Fireplace ElectricJydronic
Mechanical Sizinp. Calculations must be submitted with Plans & A
Point of Delivery must be shown on plans.
Signature of Licensed Contractor
License ux r
Date
The City of Rexburg's perm itfee schedule is the same as re)qurred by the Stale of Idaho
Zip
li'cati*on
EXEMPTIONS FROM STATE REGISTRAION
As of January 1, 2006, the City of Rexburg can no longer sell hermits without having a copy of your State
0
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 52(35, for full definitions of these excmptions
please see the State's website at VrVVW, ibol. idaho,.go lcon.t..ht}
❑ Currently State licensed pursuant to. Title 54 Idaho Code, chapters;
3 Architects,
1(] Electrical Cc►ntractarsiJourneyman,
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
0 Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit
charitable activity with no wages or salary
F-1 Employee of a US Government agency (State, City, County, or other municipality)
F1 Public Utility doing construction,, maintenance, or development to its own business
F1 Involved
with gas,
oil or mineral
operations
Supplier
doing no
ins#allation or
fabricating
0 Contracting a project or projects with a total cost less than $2000
F-1 Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building Code
1:1 Any type of water district operations
Elwork 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
t*
repair, alteration or construc ion on
11 Owner or lessee of commercial property performing maintenance.,
that property
F-1 Real estate licensee/property manager acting Within Idaho Code
Ll Engaging in the logging industry
F] Renter working on the property where they live with the property owners approval
El Construction of a building used for industrial chemical Processing per Idaho Code
F-1 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.
P
Signature
14.
0
Frint Name
7
MA
a
�� gEXB URG
I T
R.-EXBURG
CW
America's Family Community
State of Idaho
County of Madison
247
Name
city
0
BUILDING SAFETY DEPARTMENT
19 E. Main. (PO Box 280)
Rexburg, Idaho 83440
www.rexbur .
Affidavit of Legal Interest
EL
Being first duly sworn upon oath, depose and say:
Address
State
(If Applicant is also Owner of Record, skip to B)
555
"Phone: 208-359-3020 x326
Fav 208-359-3024
jn11h@rburg. or_
A. That Y 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 thl'sdfoe� �?V ay or4,4�
, 2� OL2
,F
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Pylic of Idaho
Residing t.
My commission expires:
Com..
J
f k
NOME NO■■!■■'■ OMEN!■■!■■ O■■ Mamma MANN R O M■ R Room MANN AMEN MANNA N■■ t■■■ O In MEMO MEMO aMEN IM MONO MORE OMEN
SUBCONTRACTOR LIST
Excavation & Earthwork;
Concrete
Masonry.
Roofing:
Insulation;
Dry -wall:
Pai*nting:
Floor
Coverings:
Plumbing.0
Heating:
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Cefling Joists.
iding/Fxterior Trim .
Other:
6