HomeMy WebLinkAboutAFFIDAVIT, APPLICATIONS, & TENANT FINISH - 05-00207 - Clean Spot - Tenant FinishCITY
R.EXBUNG DEPARTMENT
AMERICAS FAMILY COMMUNFFY 19 E. Main (PO Box 280) Phone: 208-359-3020 x326
BUSHEO Rexburg, Idaho 83440 Fax: 208-359-3024
w .rexburc.oro comdevidrexbura.ora
Affidavit of Legal Interest
State of Idaho
County of Madison
I, ,
Name Address
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
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:
Please complete the entice Application! If the question doe, A apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS Permit#
SUBDIVISION
Required!!!
MECHANICAL
Mechanical Contractor's Name: Business Name:
Address City State
Contact Phone: ( ) Business Phone: ( )
Email
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL4NCES COUNT (Single Family Dwelling Only)
Furnace Exhaust or Vent Ducts
Furnace/Air Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas -fired appliance
Incinerator System
Boiler
Pool Heater
Similar fixtures or Appliances
Fuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
Dryer Vents
Range Hood Vents
Cook Stove Vents
Bath Fan Vents
other similar vents & ducts:
Mechanical Sizing Calculations must be submitted with Plans & Application
Point of Delivery must be shown on plans.
Signature of Licensed Contractor
Required!
The
License number
's permit fee schedule is the same as
Date
the State
5
u
0� 0,w"�e CITY OF
� RExBURG
�4aU5N�� A'MERICASI'&MILYCOWMRINHY
'COMMUNITY DEVELOPD4E_ T
;RI XBURG-MADISON CO:
EMERGENCY SERY
APPLICATION: "CONSTRUCTION PERMIT"
CONSTRUCTION PERMIT #:_
PERMIT APPROVED: YES/ NO
-APPLICANT INFORMATION:
BUSINESS NAME:
OFFICE ADDRESS:
City
OFFICE PHONE NUMBER:
CONTACT PERSON:
APPROVED BY:
State
$50.00 FEE PAID: YES/NO
CELL PHONE #
-LOCATION OF WORK TO BE DONE:
STREET ADDRESS WHERE WORK WILL BE DONE:
BUSINESS NAME WHERE WORK WILL BE DONE: _
DATES FOR WORK TO BE DONE:
CONTACT PERSON:
PHONE NUMBER: ( 1
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
..........................................................................................,
6
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:
7
d CFFYOF COMMERCIAL TENANT FINISH
R-EXBURC; City of Rexburg
M1[RIUS fNALLY CQNMl1Nf1 Y
Department of Community Development
19 E. Main St. / Rexburg, In. 83440
Phone (208) 359-3020 / Fax (208) 359-3022
Project Information Permit # 0500207
Permit Type Commercial Tenant Finish Project Name Clean Spot
Site Address 157 N 2ND E Parcel # RPRRXB10211210
Project Description
Clean Spot
Names Associated with this Project
Type Name Contact Phone # License #
Applicant Harris, Inc 208-237-0575
Owner Northern Utah Partners Llc
Fee Information Project Details
Bid Price from Applicant
Project Valuation
Building Permit Fee
Plan Check Fee
Commercial Plumbing Permit Fee
Water Meter & Parts
Hookup Fee/Water
Hookup Fee/Sewer
Police Impact Fee
Fire Impact
Mechanical Fee Based Calulation has
Print Name
$25,000.0(
391.25
39.13
251.85
417.00
1,334.00
905.00
158.11
184.61
50.00
Total Fees Paid $3,730.95
SD
Gc�
Signature Date
Exp Date
1 TOTA
r�-OS3.(�
Date Issued:
Issued By: