HomeMy WebLinkAboutAPPLICATION - 06-00565 - Biomedics - RemodelX
CITY OF REXB UR G
BUILDING PERN1IT APPLICATION
19 E MAIN, REXBURG, ID. 83440
208-359-3020 X321
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PARCEL NUMBER-Y.,)1'��h,�i�O��jC'IC�s (W.
SL'I3DIVISION: UNI.(—A"
ddressing is based on the information - must be accurate)
OWNE.R NAME:
PROPERTY ADDRESS.
PHONE, #: Home ( )
c r l.l��q-dam I> r-7 Yt lao,
OWNER MAILING ADDRESS:
EMAIL
1�
BioM_edics-Window Replacement
LOT#
CONTACT PHONE # (71 )S
3- IZ�
Work(71V) 313 0F�(3 Cell ( )
CITY:L)f0.
Lt ST_rkTE. C� ZIP:�8(�
FAX
AEELICANT:�If other than owner)Y
(applicant if other than owner, a statement authozing appli
APPLICANT INFORNtATION: ADDRESS
STATE, ZIPI lui zN(AIL
nt to act as agent tor owner mus t accomp ny this application.)
PHONE #-. Home
CONTRACTOR.
a ,
CITY:
`tau
MIULING ADDRESS: q50 V jo, i)P rrT`v
PHONE: CeE#
EIvfAIL
r
. a I '&F -n .m.
IDAHO REGISTRATION # & EXP. DATE
How, many buildings are located on this property?
Did you xeeentl.y purchase this pro
Is this a lot split? NO YES �F1
PROPOSED USE:
(i -e.,, single Famy xe5iaen
perty&
des (If yes give owner's name
5ase ging copy of new legal description of propeirty)
ce, Niulri Family, Apartrnents, Remodel, Garages Commercial, addition, Etc.)
APPLICAN�.f'S SIGNATURE,, CERTIFICATION AND AUnder enal of r g .
`Lrt1f_L j X11
have read this application and state that the information hefein is correct nd I swear that any inf rtnation which may here -aft .
r be by mc in heanings before thef
ri
nr n ri or the L1 1Ci] for the c,-
-1ty of Rc _+.burr :5 }1 al L c truthful and correct, I agree to comply with all City regulations -id tate laws -relating
to the subs e c t matter of this application and hereby authori zed repres entatives o f the city tc) enter up onm
the above-mentiotiedproperty art for irispe tr res purposes. NOTE
The bu in ficial may revoke p =— t on app:co�-a1 igsued under the pro v'lslons of the 2003 Itit -ati i -i 1 Code in cases ofany,� `
false statement r nsrepresentatYn of fact
in. the k ti or on the l on -ivh ch the crrri t r approval -abased- Permit void if iaot started N ithin 180 d I� s. �xrYit i if wstopsy_
r
%natur at %,,o ner/zi p-acan
Do yo.Irc p
;.t ee,
.
f Com . o phonL G le One
: 1 BUILDING ISE MUST E POSTED
Plan fees are non-refundable and are paid in full at the time of appli
City of Rexburg's Acceptance of the plan feview fee does no
* Buil ding P mit Fees are due at time of application** u l in Fermi,
DATE
c inning y
'tu'tutlr n approval ;a..
�r check
R
CITY
OF REXBURG
Building Safety Department
19 E. Main
Rexburg} 183440
State of Idaho
County of Madison
7 1i
Name/
F�
Clty,
jane11h@rexburg,org
www.rexburg,org
City of Rexburg
Phone. 208.359.3020 ext 326
Foy: 208.359.3024
Affidavit of Legal Interest
Being first duly sworn upon oath, depose and say:
s
h
CITY
EXB.URG
America's Family Community
L � ■ �
State
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described an the attached, and I 61 -911 -ant my
permission to;
- m'k'-
Name
to submit the accompanying application pettaini.ng to that property.
B. I agree to �ndemm'fy, defend and hold Rexburg City and its employes harmless from any
claim or liability resulting from any clispute as to the statements contained herm*
or as to the
ownership of the prope-tty which is the subject of the application.
Dated this
Signature
day of
subscribed and sworn to before me the day and
I
first above wnYen.
Lary Public of Idaho
Residing at:
My comimssion. expites:
3
-dW
Please complete the entire Application!
If the question does not apply fill in NA for non applicable
NAME �jjp•Y'V1��lGS j C��I�Y G77f�!(1f�LL
PROPERTY ADDRESS MAW
SUBDIVISION
Dwelling Units;
SETBACKS
FRONT SIDE
Parcel Acres:
SIDE BACK
Remodeling Your Buildrtxg/Home (need Estimate) $C��•
Pe-mu't#
SURFACE SQUARE FOOTAGE.- (Shall m'clude the exterior wall measurements of the building)
First Floor Area
Second floor/loft area
Third floor/loft atea
Shed or Barn
Water Meter Quantity:
Regzzired.!f!
PLUMBING
Unfinished Basement area
Finished basement area
Garage area
Carport,/Deck (30" above grade)t1tea
Water Meter Size,
Plumbing Contractor's 1Vame: Business Name:
Address city State ZIP
Contact Phone: Business Phone. � }
Ei-nai1 Fax
FrxrunE coUrrT ;,,��„�
toughed fixtures
- Clothes Washing Machine
Dishwasher
. Floor Dram
Garbage Disposal
Hot Tub/Spa
Snks
(Lai-atiories, kitchens, baz, mop)
Plumbing Estimate $
Required!
5pfinklers
Tub/Showers
Toilet/Urinal
Water Heater
Water Softener
(Commercial Only)
Signature of Licensed Contractor License number Date
Th e Cit IS
Y Ypermiffee sclvdiile ' the same ar required by the State of Idaho
f Rexbu):
El
Please complete the entire Application.1 If the question does not apply fill in NA for non
applicable
NAME
PROPERTYADDRESS Permit#
SUBDIVISION
Required.!!
Mechanical Contractor's Name:
MEC
Business Name*
.address City State
contact Phone: ( ) Business Phone: ( )
;mail Fax
Mechanical Estimate $ (Cvmmercial/Multi Family Only
FIXTURES &APPLIANCES COUNT (Single FanidyDweAing Only)
Furnace Exhaust or Vent Ducts
Fu,rnace/Air Conditioner combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas-fired applian
1nCm*e_rator System
Boiler
Pool Heater
Fuel Gas Pipe Cutlets ita.cluding stubbed
Inleti Pressure (NIeter Supply) PSI
Heat (Circle all that apply)
0
oint of
�
n or future outlets
Coal Fireplace
Requiredl -
0 ignature of Licensed Contractor
elive
Dryer Vents
Range Flood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents &duces:
Electric Hydrop0
ic
Ucense number
Date
' �uf Rffxbatspenwiffte i-cf)e(Nie is Me same as required ig the Rate ojldaho
.
Zip
5
RIIIIP�1�'1M CMf�i�• 1�1w w.�..i.Y �.�l
19 EM i
Rexburg, 0 83440
jane11h,@rexb urs'. orgL
www.rexburg.org
OWNEWS NAME
PROPERTY ADDRESS
SUBDIVISION
PHASE LOT BLOCK
vWNcarnenr oFpE' Jr
City of Rexburg
Phoney 208.3,59.3020 x326
Fax' 208-359.3024
Regzured.�l.� ELECTRICAL
Electrical contractor's Name Business Name
8J1EID
Address CityT State
CeU Phone ( } Business Phone
Fax
Email
I
CITY 0 F
REXBU
RG
Americas Family Community
Electrical Estimate (cost of wiring & labor) $ (COMMERCIAL/MULTI-FAMILY ONL
TYPES OF INS TAL-LATION
(Ne w J?e siden tial in clu de s e verytbing c on taiti e d vpithin th e residen tial s tru Ct tire an d a tta ch e d garage a t th e s atn e titn e)
Up
to 200
atnp
Se -t -vice*
201
to 40a
imp
Senrice*
Over 40D amp Sexvice=�
Existing Residential (# of Branch Circuits)
Temporary Construction SenTice,, 200 ami or less, one location (for a period not to exceed
spa, Hot Tub., Swimming Pool
1
Electric Centtal Sy=stems Heating and/or Coaling (xvhen not part of a new residential construction pernvt
and no additional wIAng)
N'Todulat, Manufactured or Mobile Home
ether Installations; Wiring not specif cal1y covered by any of the above
Cost of Wiring & Labor:
Pumps (Dotnestic Water,, Irrigation, Sewage)
Requested Inspections (of existing wiring)
Temporary Amuse
-ment/Industry
*Ineludes a maximum of 3 inspection. Addifional inspections charged at requested inspection rate of $44 per hour.
si'vaturef I -ilcensed Contractor
License. number
Th e Cit
of Rsx �' permit e . ch edul
e Is,thesame .�required
-Me State, of f
Date
31
0
Building Safety Department 11A�q
19 E. Main
Rexburg, ID 83440
www.rexburg.org
City of Rexburg
Phone, . .30
Fox.., .. 208.359.3024
APPLICATION: "CONSTRUCTION PERMIT"
M
Nfs:44
CONSTRUCTION PERMIT #:
PERMIT APPROVED: YES/ NO $50.00
APPROVED BY:
-APPLICANT INFORMATION -
Business Name*.
Office Address:
I TY 0 IF
Cw
Americ6 Pamir' ' j�j n
FEE PAID: YES/NO
Office Phone Number:—,) �( Cit}' State ZIP
Contractor Performing the Work:
Contact Person: Cell Phone # ( }
-LC3CATION OF WORK TO BE DANE:
Street Address Where work Will Be Done:
Business Name Where Work Will Be Done:
Dates For 'work To Be Ione: To
Contact Person.
Phone Number: t } CeR # � }
PLEASE CHECK THE TYPE OF PERMIT(S) YOU ARE APPLYING FOR:
❑ AUTOMATIC FIRE -EXTINGUISHING SYSTEMS
❑ COMPRESSED GASES
Ll FIRE ALARM AND DETECTION SYSTEMS AND RELATED EQUIPMENT
FIRE PUMPS AND RELATED EQUIPMENT
❑ FLAMMABLE AND COMMBUSTIBLE LIQUIDS
❑ HAZARDOUS MATERIALS
INDUSTRIAL OVENS
F -I LP -GAS
1-1 PRIVATE FIRE HYDRANTS
E-1 SPRAYING OR DIPT'ING
❑ STANDPIPE SYSTEMS
TEMPORARY MEMBRANE STRUCTURES, TENTS, AND CANOPIES
,Applicant3s Signature D atc -
7
SUBCONTRACTOR LIST
Excavation & Eatthwotk:
Concrete:
Masonxy:
Roofmg:
uInslati,
Drywall:
Pal*ndng:
Floor
coverings:
Plumbillgo
Heating.,
Electtical:
Special Constmction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceilingjoists:
Siding/Exten,"or Trim-,
Other:
N
EXMPTIOiNTS FROM STATE REG -Is RATION
As of January 1, 2006, the City of Rexburg can no longer sell pellmts without having a copy of your State
re,gistr�,tion number or your exemption from the State registration. Please send a copy of your sate registration or
fill. out this form showing roux exemp�on and send it with your license renewal ox your nextemit application.
p p�
(This list is a summarization of Idaho Code Title 54 Chapter 5205, for dull definitions of these exemptions pleas.
see the State's website at vrww.ibol.idaho.Qrovlcnnt.ht-m�
❑ Currently State licensed pursuant to Title 54 Idaho Code,, Chapters:
3 Architects,
10 Electfical Cont-tactors,/Journeyman,
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 onlytroqu,r
50 Installation of heating, ventilation and air conditioning systems
❑ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit charitable
activity urith no wages or salary
❑ Employee of a US Government agency (State, City, County, or other municipality)
❑ Public Uty doing canstruetion, maintenance, or development to its own business
a Involved with gas, oil or mineral operations
❑ Supplier doing no installation or fabricating
❑ contracting a project or projects with a total cost fess than $2,000
❑ Operation of a farm or ranch or construction ofagriculture buildinvs exempt fro o g Cade
a Any type of Latex district operations
❑ Work in mal districts for fire prevention purposes
❑ Owner who performs work on own property or contacts with a registered contractor to do work as long as
the property 'is not for resile within 12 months
❑ Owner or lessee of commercial property perforMlng maintenance, repair, alteration or construction on that
property
❑ Real estate licensee /property manager acting within Idaho Code
a
Engagingin the loggm'g industry
❑ Renter working on the property where they live with the property owners approval
� Construction of a building used for industrial chemical Processing per Idaho, Code
❑ Construction oaf a modular building (defined by Idaho Code) to bernoved out of state
T hereby cerfif� that the above i.nfQxmati.on is due and correct to the best of my knowledge.
Signature mate
Print Name