HomeMy WebLinkAboutAFFIDAVIT - 05-00106 - Rexburg Rehab - Tenant FinishCITY OF
COMMUNITY DEVELOPMENT
L[Jy REXBURG
AMFRICAS FAMILY COMMUNITY 19 E. Main (PO Box 280) ' Phone: 208-359-3020 x326
BGsr�E° Rexburg, Idaho 83440 Fax: 208-359-3024
www.rexbuuq.om comdev�a rexburo.ora
State of Idaho
County of Madison
I,
Name
City
Affidavit of Legal Interest
Address
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
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 herin or as to
the ownership of the property which is the subject of the application.
Dated this day of 120
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
CITY OF
REXBUNG
�98[ISHEO �� NMI-RICAS Iv1iMILY COk6NUNI IY
Rexburg, Idaho 83440 Fax 208-359-3024
w .rexburg.org cdd@rexburg.org
APPLICATION: "CONSTRUCTION PERMIT"
CONSTRUCTION PERMIT #:
PERMIT APPROVED: YES/ NO $50.00 FEE PAID: YES/NO
-APPLICANT INFORMATION:
BUSINESS NAME:
OFFICE ADDRESS:
city
OFFICE PHONE NUMBER:
CONTACT PERSON:
-LOCATION OF WORK TO BE DONE:
APPROVED BY:
State
CELL PHONE #
STREET ADDRESS WHERE WORK WILL BE DONE:
BUSINESS NAME WHERE WORK WILL BE DONE: _
DATES FOR WORK TO BE DONE:
CONTACT PERSON:
PHONE NUMBER: ( )
TO
CELL # ( )
PLEASE CHECK THE TYPE OF PERMIT(S) YOU ARE APPLYING FOR:
Zip
❑ AUTOMATIC FIRE -EXTINGUISHING SYSTEMS
❑ COMPRESSED GASES
❑ FIRE ALARM AND DETECTION SYSTEMS AND RELATED EQUIPMENT
❑ FIRE PUMPS AND RELATED EQUIPMENT
❑ FLAMMABLE AND COMMBUSTIBLE LIQUIDS
❑ HAZARDOUS MATERIALS
❑ INDUSTRIAL OVENS
❑ LP -GAS
❑ PRIVATE FIRE HYDRANTS
❑ SPRAYING OR DIPPING
❑ STANDPIPE SYSTEMS
❑ TEMPORARY MEMBRANE STRUCTURES, TENTS, AND CANOPIES
APPLICANTS SIGNATURE DATE
..........................................................................................,
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SUBCONTRACTOR LIST
Excavation & Earthwork:
Concrete:
Masonry:
Roofing:
Insulation:
Drywall:
Painting:
Floor
Coverings:
Plumbing:
Heating:
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists:
Siding/Exterior Trim:
Other:
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