HomeMy WebLinkAboutAPPLICATION - 06-00527 - The Back Smith - RemodelCITY OF ]?E.XB URG
BUILDING PERMIT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X322
PARCEL, NUMBER:
Please
If the quc
0600527
The Back Smith Remodel
Nutst�iV1SION: �we wili provide this for)rn,l
- Addressing Ul'�IT#
is based an the if�on -must be acc���-ate
OWNER'
PROPERTY ADDRESS: �, FFMwrr
PHONE #: Home
CONTACT PHONE #
�_�s`SY_v&uork
OWNER MAILING ADDRESS
EMAIL;M�n�r��„JP,a�, �
��N IaTF: s-AziP. 8?vye
FAX
ALPLICANT-
(If other than owner)
(Applicant
if other than owner, a statement author"'
izing applieant to act as agent for o� '
g ��ne
must accompany this application.)
APPLICANT INFORMATION: ADDRESS '1 1 , CITY:
ell
STATE; EMAIL''hc, -FAX
PHONE #: Home Work (�:;;�j_i.�i %� c��/3 Cell
CONTRACTOR: III
MAILING ADDRESS:
S-0
CTT'� s:�t). ",� STA
PHONE; Homei
EMAIL
J'�
L .11I
TE.c ZIP
Hew many buildings are located on this pro,. erty9lcl %mom.Did you recez�ily purchase thzs fro ert `�I� Y• e� (If yes give av�meIs this a 10t split?�ryES �(please brin cog py of new legal descr of property)
3PROF4S:ED USE:� ��(i,e., Single Family Residence, Multi Family, Apa�trnents, made Garage Comp � g ����er�ia AdditionEtc.
APPLICANT"I SIGNATURECERTIFICATION AND AUTHORI A
read this rli 4
TI certifyt�tie t�t t� infrntnri correct and
Ireht any rs inforniation whi
and Zoning Comni.,isston Or the CitV Council for the. � f - � � �1 en me in iii before thePlanning
����� ��11. � tru�ful mid correct, I re �� comply ��ri�l� X11
ub eet in tter 0f this applie ti �d herb authorized r re � �it regulations� t��� 1���F� rel tii�� t the
nt ' e f th r to inter' u oii the above- nt1 ding official may revoke pe lnit on approvalInternational
toned property for in pe tion purposes. NOTE., The.it��ro provisions the 2 00 Int rn tion l
Code in cases f -an false statement
t�. application r �. the1� n �� 4 �ii�i tl�e r� it � F � r ��r� re�e��t�ti��� �I fact ,
r r � based- Perm' v i if t started within I days, l�e���i void F � t �r�
t � � � rI workstops for 1 �a�,
S:rg'natrare of Owner/ plicant DATE ��
Da you prefer to be contacted bv fax email nr �,��►nP9 r�;,.�.I� �,w,�
W"NING — BUILDING PERMIT MUST BE POSTED ON CONSTRUCTIOX SITE!
Plan fees are nan-refundable and are paid in full atthe time of application I)eginning Jantfa 00 -
City of Rexburg's Acceptance of the plan review fee does nOt constitute
CITY C _
f..EXBUF�,G,
&MERiCt1'S FAMILY CC7NAMUN1 FY
State of Idaho
County of Madison
or J
Name
g
M.
_,.�... ki � vnn; 208-359-3020 x326
Rexburg, Idaho 83440 Faxen -
Af#idavit of Legal Interest
0)
M
Address
lo 4,4 ..
City State
Being first 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 on the attached, and I grant my
pennission to: A,) CA Ln S if%4 � ilefn_� �.
NameAddress '
to submit the accompanying application pertaining to that property.
B. I agree to indemnffy, defend and hold Rexburg City and its emp7ayees harmless from an
claim or liability resulting from any dzspute as to the statements contained herin or �.s to y
the ownership of the property which is the subject of the applicatiol1.
Dated this � �, day of � t � -,20
Sign'ature
Subscribed and sworn to before me the day and year first above written.
*vlx%e
wr'°re o1F
III
Notes P
lac O'f Idaho
Residingat:
MY Commission exit
IN
"Building Permit Fees are dro"'o time of application" 'Building Permits are voM if you check does not clear"
e pleaase cvmplete the entire App�lc�tion.
jIf
1
111,10? the question does not aPPIY fillin NA for non aDDUCable
1'NtAMEi'► C
'I ZAK t i
PROPERTY ADDRESS �� m� ,
.t
f� vx � �
SUBDIVISION ��
Dwelling Units -I. Parcel Acres:
SETBACKS
FRONT SIDE SIDE
BACK
Permit#
Remodeling YourBuilding/Home (need Estimate) $ ���0 ��
SURFACE SQUARE, FOOTAGE: (Shall 'Include the exterior wall measurements of the building)
First Floor Area � � �' �� f � fi
Second floor/loft area
Third floor/loft area
Shed or Barn
Water Meter(quantity::
Required!!!
PLUMBING
Plumbic
Address
Unfinished Basement area
Finished basement area
Garage area
Carport/Deck (30" above grade)Area
Water Meter Size:
Contact Phone: (*10j1e
SII
Sia�qw,m�
zip
Business Phone- 2513 7T--- ,�—..-� r O
-
Email Fax
FIXTURE COUNT (includin
ro ygh ed fixtures
Clothes Washing Machine
Dishwasher
Floor Drain
Garbage Disposal
Hot Tub/Spa
Sinks
(Lavatories, kitchens, bar, mop)
Plumbing Estimate $V �"�
(Commercial Only)
Requi
SF�
V
Liven C, CQtlt--actor The City License number Da
OfReXhUrg, JSPeP7nit,.fee schedule is the same as required by the State St
ate ofIdaho
Sprinklers
��`��Tu -Showers
�� oile',,- rinal
Water Heater
Water Softener
4
Please complete the ent*1�Appl &cation� If the question doer_M*4N't apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS � ...
SUBDNISION
Requited!!!
MECHANICAL
r ermit#
Mechanical Contractor's Name: Business Name:
Address CitY State Zip
--------
Contact Phone-, ( ) Business 'hone: ( }
Email Fax
Mechanical Estimate $
FIX -TU -RES & APPLIANCE
Air Conditioner
Bath Fan Vents
Ranke Hood Vents
Boiler
Cook Stave Vents
Decoratiffive Gas Fire
Dryer Vents
Evaporative Cooler
Exhaust or vent ducts
(Commerciall/Multi Family Only)
OUNT
_
(Single Family Dwelling Only)
Fuel {gas) piping f xtures or appliance I
Furnace
Fumace/Air Conditioner Combo
Head Pump
Incinerator
Pool Heater
Heat (Circle all that apply) Gas
Coal
Spare Heater
Unit heater
Mechanical Sizing Calculations multi be submitted with Plans & A1*cation
Point of Delivery muni be shownpans.
on 1 PA
S i nturLicensed ntrac f o r
Req,u*1red
License number
Date
The City " .yb 's peg M itfte schedule s the lain
1' by the, State ofldaho
5
CITY OF
f.zs�---.EXBUf G
AMERICAS FAMILY CONtl1IL€NrFY
Rexburg, Idaho 83,440
www. re � rte!
APPLICATION: " CONSTRUCTION PERMIT"
mane: 208-359-3020 x326
fax; 208-359-3024
cdd@rexburg.org
CONSTRUCTION PERMIT #;
PERMTT APPROVED: YES/ NO $50.00 FEE PAID:
-APPLICANT INFORMATION:
BUSINESS NAME:
OFFICE ADDRESS:
APPROVED BY:
City State
OFFICE PHONE NUMBER; ( ) Zip
CONTACT PERSON: CELL PHONE #
-LOCATION OF WORK TO BE DONE:
STREET ADDRESS WHERE WORK WILL 13E DONE:
BUSINESS NAME WHERE WORK WILL BE DONE:
DATES FOR WORK TO BE DONE; CONTACTPERSON:
PHONE NUMBER: ( ) CELL #
PLEASE CHECK THE TYPE OF PERMIT(S) YOU ARE APPLYING FOR:
Ic
r7 AUTOMATIC FIRE -EXTINGUISHING SYSTEMS
LI COMPRESSED GASES
L1 FIRE ALARM AND DETECTION SYSTEMS AND RELATED EQUIPMENT
Ei FIRE PUMPS AND RELATED EQUIPMENT
FLAMMABLE AND COMMBUSTIBLE LIQUIDS
HAZARDOUS MATERIALS
INDUSTRIAL OVENS
1:1 LP -GAS
PRIVATE FIRE HYDRANTS
r� SPRAYING OR DIPPING
J STANDPIPE SYSTEMS
E-1 TEMPORARY MEMBRANE STRUCTURES, TENTS, AND, CANOPIES
YES/NO
APPLICANTS
�....�..�.�..�.� DATE
a MERU MAKER now MARRS amall R 0 MEN 111104 & MEMA gong Mumma NMI
0
SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:
Masonry:
Roofing,
Insulation:
Drywall:
4
Painting,
Floor
Coverings:
a
Plumbing:
Heating:
Electrical:
SpeeialConstruction
(Manufacturer or Supplier)
Roof Trusses.
Floor/Ceiling Jo�sis:
Siding/Exterior Trim:
m
0
Otheir.
7
EX MP TONS FROM STATE R
As of January 1, 2a06, the CAY of Rexburg can no longer sellperm*tsreg1sirat�Qn number ar your exemptYon firom the Stale re istratio�n. without having a copy of your state
registration or fill out this form showing your exem tip and �e send � copy a� your stat
0
nest permit application. p nd it with your license renewal or your
(This list is a summarization of Idaho Code Title 54 Chapter 5205,for �iz�l d�f n�tYons of thes
please see the State's website atvvtivw.ibol.idaho. ovlcant.htm e exemptions
�
Currently State licensed Pursuant to Title 54 Idaho Code., Chapters. -
3 Architects.)
� D Electrical Contract ors/Jo urneyman,
12 Engineers/Surveyors,
19 Public Warks Contractors (exempt from fee only re
gistraiian required
26 Pluml��ng,�PZumbers, ),
45 Public Works Construction Management Licensing Act(exempt from fee onlrequired}, oxy reg�s�raiion
SQ installation of heatilng, ventilation and air conditioning systems
� Employee or volunteer of a license. contractor or pert of an educational curriculum
chartable activity with no images or salary or nonprofit
El Employee of a US Government agency (State., City, County, or other municipality).
Public Utility doing construction, maintenance, or development to its ownbusinesspy}
0 Involved with gas, ail or mineral operations
0 Supplier doing no installation or fabricating
11 Contracting a project or projects, with a total cosi less than $2000
1:1 operation of a faun or ranch or constructibuildings e��mon of agr�cu�ture t, from fdaho��dep Building
1:1 Any type of water district operations
❑ Work in rural districts for fire prevention purposes
Owner who performs work on own property or contrasts with a registered contractor to do work as the property is not for resale within 12 months
work as
Ei Owner or lessee of commercial property performing maintenance, repair, alteration or cons
on that properly construct*
[i Real estate 1icenseelpr�perty manager acting within Idaho Code
D' Engaging in the logg-ng industry
DRenter working on the property where they live with the properly owners aravai
11 Construction of a building used fog industrial chemical processmPp
n Idaho CodeConstruction of a modularodular building (defined by Idahobode to bg er moved o
out of slate
I hereby certify that the above, information is true and correct to the best of my knowledfze..'
Signature
Print Name
Dale