HomeMy WebLinkAboutAPPLICATIONS, BP - 06-00025 - 4459 W 1000 N - Gas LineZ
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' C,~'1 ~'Y OF REXB UR G
BUILDING PERMIT APPLICATION Please c~
19 E MAIN, REXBURG, ID. 83440 If the questi
208-359-3020 X322 n I
PARCEL NUMBER: ~~Q~,! V ~ ~ ~ ~ ~'i ~ I (W~
PRR MTT #f
Ob 00025
4459 W 1000 N-Mad. Co. IVlech.
SUBDIVISION: UNIT# BLOCK# LOT#
(Addressing is based on the information -must be accurate)
CONTACT PHONE #
PROPERTY ADDRESS: `,~`FS`1 GtJcs f- f0®o ~a-~,~ ~~~~ ,~~ ~s~S~a~
PHONE #: Home ( ) Work ( ) Cell ( )
OWNER MAILING ADDRESS:S~S l ~/ l~v ~ CITY: ~2~ STATE: ZIP:
EMAIL
FAX
~3 ~O
APPLICANT (If other than owner) f ~~~
(Applicant if other than owner, a statement authorizing
APPLICANT INFORMATION: ADDRESS
nt t6 act as agent for owner must accompany this applicatiorf.)~
ct~ ~`!~~ CITY: ~~~-~~
STATE; ~~ ZIP g3~~ EMAIL /Sl /-I- FAX Zvg ~z~ 3 77~
PHONE #: Home ( )
Work (2~~ 6ZSF-37~ Cell (~~' 3 `tom 3 ~~
CONTRACTOR: 6~,~ ~-s ,~~;r~lsQ~c ,t;l.d3aci~
MAILING ADDRESS: CITY STATE ZIP
PHONE: Home# Work# Cell#
EMAIL FAX
How many buildings are located on this property?
Did you recently purchase this property? No Yes (If yes give owner's name)
Is this a lot split? NO YES (Please bring copy of new legal description of property)
PROPOSED USE: `~e~f~~ c~
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify
that I have read this application and state that the information herein is correct and I sweaz that any information which may hereafter be given by me
in hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply
with all City regulations and State laws relating to the subject matter of this application and hereby authorized representatives of the City to enter
upon the above-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the
provisions of the 2000 International Code in cases of any false statement or misrepresentation of fact in the application or on the plans on which the
permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days.
/ /_
Signature of Owner/Applicant DATE
Do you prefer to be contacted by fax, email or phone? Circle One
WARNING -BUILDING PERMIT MUST BE POSTED ON CONSTRUCTION SITE!
Plan fees are non-refundable and are paid in full at the time of application beginning January 1, 2005.
City of Rexburg's Acceptance of the plan review fee does not constitute plan approval
**Building Permit Fees are due at time of application** **Building Permits are void if you check does not clear**
t
A ~
Please complete the enti~Application! If the question does not apply fill in NA for non
applicable
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
Required!!!
MECHANICAL
Mechanical Contractor's Name: ~-~~ r C~ /~.---/> Kc- Business Name:
Address ~ ~ /`t rat-eF. City ~~ State ~ Zip
Contact Phone: (~~~ s.. Z ~ 3 7 ~ ~ Business Phone: ( ) ~ Z ~ ~ ? 7 z
Email.
Fax ~2 ~ 3 77~{
Mechanical Estimate $ (Commercial/Multi Family Only)
FIXTURES & APPLL9NCES 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.
6~f
Sign of Licensed C tractor
~jc _ G _// c~6
License number
f ~ D5
ate
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho