HomeMy WebLinkAboutAPPLICATIONS - 06-00406 - 1180 S 2nd E - New SFRCITE OF REX
BURG
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X326
PARCEL NUMTA
'KPR'
SUBDIVISION:
(Addressing is based on the itni
OWNER NAME:
Plea
If the (
ID rD X ifIFF
0600406
1180
S2n.d _E.�Bl.aser
d;14W
tTNIT#
tmation - must be accurate)
�0�
PROPERTY ADDRESS:
1�
Ac
row
BLOCK#— � L0T#'_1 •b'- 1.1b
y' 0 fis CONTACT PHONE #
1-rz66
PHONE #.-Home ( ) Work ( ) Cell ( ) `? � l- (2 6 [
OWNER MAILINU ADDRESS: 30�. h.1��iu,,,1� CITY:- STATE:� ZIP: Y._-Sy4o
EMAIL
FAX
APPLICANT (If other than owner} L -S6 R (z,4o„��,,,��,.�,,;
(Applicant if other than owner, a statement authorizing applicant to act as agent for owner mist accompany this application.)
APPLICANT INFORMATION: ADDRESS—
S TATE;
ZIP �,MAIL
PHONE#-. Home
CONTRACTOR:
MAILING ADDRESS:
Work ('
A 1--- (4( L— s',
R
aw�1,Lo. ,b
Llo", —,,e-
Gts%3
CITY:
FAX
Cell ( )
2c�L
F `f(5br�" CITY ��i-54-� STATE ��• ZIP t1i 5' -(**4 d
PHONE #: Home 3r% -f-S'Vi 4Work ( )_ '34 ; 1 Cell
EMAIL
FAX'4S';�-Elilj IDAHO REGISTRATION # & EXP DATE L'SwO
How many bwldmgs are located on this property? "'o —
Did you recently purchase this property? No Yes (If yes give owner's name)
Isthis a lot split ? �^ """ 'r'
PROPOSED USE:
(i.e, Single Family ResJ
APPI IU U fJWWL=j
SIGNATUREn 7
that I �����T read thi �. licatin �..tt Under �� �� r�ur, I r-� i�`
that the information herein z correct and I swear that rY in fo r i
application
i b mei hearingsbefore the l in ndiiin� � t �Council the it f efc pi with all C' lat'x
subject rnatterf this nd herbUPater
���irinspections
11 9
x I ,
itv,regu ions and State laws relating to the
.. TE: Thebuil inofficial may revoke o rr� itn. '
xOii�r�e �`�� �r�trr�t�r�.� its �misrepresentation
�r � 1uunder the
l t t r t r mi r pr nt t of fact in the or '
it approval tx if - 1ratrrr r.i t
not started within 1 ����r�it �'i �#�� � �`� � �:,
I _ .
I n. tur Owner/Applicant
J
you preler to be cont fax email or phone? Circle One
WARDING -- .BUILDING PE IT MUST IBE POSTED ON CONSTRUCTION
Plan fees are non-refundable and are paid in full at the time of appilocation beginning Janum Acceptance . Permits
o�
005.
� -- �� ��� �u� 'othe plan review fee d not constitute ut plan approval Permt 'ears du t time oa`eai application** "Building ..�
Perm its .re vol if your check do notdear**
3
V'XBV
-I)
&0
RF x-BuRG
America -s' Fainily Community
State of Idaho
County of Madison
19
Name
BUILDING SAFETY DEPARTMENT
19 E. Main (PO Box 280)
Rexburg, Idaho 83440
www. rexburrri nr
Affidavitof Legalinterest
city .5
Being first duly sworn upon oath, depose and say:
Address
State
(If Applicant is also Owner of Record, skip to B)
Phone: 208-359-3020 x326
Fax: 208-359-3024
i
Lqne11h(q-)re)q,rburg_ ora
A. That I 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 orliability01P resulting from any dispute as to the statements contained herein or as to
* 4
the ownership of the property which xs the subject of the application.
Dated this
Signature
Z:)
day of Zp
Subscribed and sworn to before me the day and year first above wr-
itten.
Notary Public of Idaho
Residing at:
MY commission expires:
2
Please complete the entire Application!
If the question does not apply fill in NA for no applicable
NAME �ASO R (,�wg}-
PROPERTY ADDRESS )-.ij �+- Permit#
SUBDIVISION L &.lfEy
Dwelling Units.LtParcel Acres: - �t 3 Atm>i
SETBACKS
FRONT- Sc -r SIDE S� T SIDE Q o + BACK
Remodeling Your BuildinglHome (need Estimate) $
SURFACE SQUARE FOOTAGE.: (Shall include the exterior wall measurements of the building)
First Floor Area Js -2-. 1 �,
Second floor/loft area
Third floor/loft area
Shed or Barn
Water Meter Quantity: f),
Required!!!
PL
UMBING
Plumbing Contractor's Name:
IV 1k
Lug,
Unfinished Basement area
Finished basement area
Garage area - �
Carpo/Deck ( above grade)Area
Water Mete- Sizc:
Business Name:
+
Address City State-
Contact
Phone,, ( )---3'S---�--1---,Business Phone: (
Email
FIXTURE COUNT(in cluclin rouixi,erfy-xtures
low
Clothes Washing Machine 3
r� Dishwasher
� Floor Drain 7,
Fax
Sprinklers
Tub/Showers 47
-i,�` _ To*1et/Ur*na1 �B
� Garbage Dposaisl 'Water Heater
I -lot Tub/spa z� Water Softener
Sinks f
(Lavatories, kitchens, bar,, mop)
Plumbing Estimate S (Commercial Only)
ature of Licensed Contractor 4i�ccense number p �
The City of Rexbtrrg s permit, fee schedule is the same as required 6y the State �
KE
f Idaho
Zip
pr
'Please complete t
applicable
NAME_
PROPERTY ADDRESS
SUBDIVISION
L
Required!!!
he enti"re A pp1*jCation. If the question does not apply fill in NA for non
Mechanical Contractor's Name:
Address� .,
Contact Phone: (-Zo
Email
Mechanical Estimate S
.... . .. .. .. . .... ....
MECHANICAL
. P by i
7 5 �3
Perrnl*t#
b4�Business Name: � e-iC-A:.r�
_City ��v� k6� —State J ---r
.
Business Phone: ( 35L 9) `=? o
ia�s
(Commercial/M 1 i Family Only)
FIXTURES & APPLIANCES COUNT
Furnace
(Single Family Dwelling Only)
10' Exhaust or Vent Ducts
Fumace/Alr Conditioner Combo'15'
Dryer Vents to
Heat Pump
Air Conditioner
Evaporative Cooler
Unit heater 15"
Space Heater
r
Decorative gas-fired appliance $V
Incineratar System
Boiler
-Pool Heater
Similar fixtures or Appliances
V ruet teas ripe Uutlets includi*ng stubbed xn or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
r
Range �-Iaod Vents
Cook Stove Vents
Bath Fars Vents
�{ �
M,s
s
other similar vents&ducts:
Z70
Mechanical Sizing Calculations rust be submitted with Plans & Application
Point of Delivery mush be shown on plans,
Sign
of Licensed Contractor
1C, (0 - /
t
License number
-PO f�-66
Date
The City of Rexburg's Permit, fee schedule is the safne as required by the State a_,{Idccha
5
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WERMENEff
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:-'-. bbj,
Masonry: I
Roofing,
ve
Insulation:
Drywall: tX ks
Painting:
Floor
Coverings:
Plumbing:
Heating:
Electrical:
41
Special Construction
(Manufacturer or Supplier)
Roof Trusses: rvv,��
Floor/Ceiling Joists: '2, i
Siding/Exterior Trim.,, .7.
ether:
EXEMPTIONS FROM STATE REGISTRATION
As of January 1, 20061 the City of Rexburg can no longer sell permits without havina co9py of your State
registration number or your exemption from the State registration, Please send a copy of your stag registration
car fill out this form showing your exemption ani. send it with your license renewal o� your newt permiat
applicat1on.
(This listis a summarization of Idaho Code Title 54 Chapter 5205., for full definitions of then; exemptions
please see the Skate's website at v�u-w�.ibol.idAa.gavlcant.htm)
F-1 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,
2�6 Plumbing/P lumbers,
45 Public Words Construction Management Licensing Act (exempt from fee only registration xequir�c��,
or
F-1 50 Installation of heating, ventilation end air c�n�ioni
ding systems
Employee or volunteer of a ficensed contractor or part of an educational curriculum or nonprof t
charitable activity With no wages or salary
❑ Employee of a US Government agency (State, City, County, or other municipality)
❑ Public Utility doing construction, maintenance, or development to its own business
❑ Involved with has, oil or mineral operations
El Supplier doing no installation. or fabricating
El Contracting a project or projects with a dotal cost less than$'-. 000
D Operation of a farm air ranch or construction of agriculture buildings -exempt from Idaho Buildi*ngbode
Ani type of water dis�xPct 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 properly is not for resale within 12 months
0 Owner or lessee of commercial property performing maintenance, repair, alteration or consiruction on
that property
❑ Real estate licensee/property manager acting within Idaho Code
Q Engaging in the dogging industry
1:1❑ Renter warping an the property where they live w1ih the property av�ers approvalConstruction of a building used for industrial chemical proce
ssing per Idaho Code
F-1Constructionof a modular building N,
(defined bY Idaho Code) to be mowed out Of state
I hereby certify that the above information is true and correct to the best of my knowledge.
Signature Date
Print Name
7