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City o, f Rexburg/ Madi County PERMIT # -
' BUILDINGPERMITAPPLICON ~ 1~~~~~~ g.~~.it.tl~lt~:€ #i~~,~`~i~i~•~= ~~~ir~~€ ~~i~~~~.
19 E MAIN, REXBURG, ID. 83440 fi ~' x: ~ r 4 ~ . ~ ,
208-359-3020 X322 0( 00093
PARCEL NUMBER:
SUBDIVISION: L 5041 W 5000 N-Cnty Mech.
(Addressing is based on the information -must be accurate)
-------
~ CONTACT PHONE # 35f - c~ ~`?
PROPERTY ADDRESS: 5~b~ ` ~ ~~ T SZ~ ~~
PHONE #: Home (aff6) 35~--~~~`~ Work {2og)_ 3~t -v~~? Cell ( )
OWNER MAILINGADDRESS:_. ~~C~~ ~~ ho~vG CITY: ~ Z~~; STATE: t® ZIP:~O
EMAILkrcoNsttzv~Z~:~.-c~r~`t~= ~.~F~"~` 3S~- NSA(
Al'PI.LCAIVT: (If other than owner)
(Applicant if other than owner, a statemetrt authorizing applicant to act as agent for owner tmnst accompany this application.)
APPLICANT INFORMATION: ADDRESS CITY;
STATE; ZIP EMAIL FAX
PHONE #: Horne ( ) Work ( ) Cell ( )
CONTRACTOR:
MAILING ADDRESS: t W~~~ ~;~ NU~~ CITY (L~~g~~ STATE 10 ZIPP~~~~lo
PHONE: Home# ~ ~~S g~ Work# 3S~ -o ~ a~ Cell#
EMAIL FAX_ "~ ~ - 5~~
How many
are located on
Did you recently chase this
Is this a lot spli . NO YES
PROPOSED USE: i iJ (;
(i.e., Single Family Residence, Multi
property7~ Yes (If yes give owner's name)
(Please bring copy of new legal description of property)
~,FPM^l~ ~Si ~ ~ ~
Family,
Remodel, Garage, Commercial, Addition, Etc.)
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of pequry, l hereby certify that I
have read this application and state that the information herein is carrect and I swear that say information which may hen~fter be given by the in hearings before the
Planning and Zoning Commission or the Ctty Conrail fior the City of Itexbwg shat! be tntthful and correct, I agree to comply with all City regulations and State Taws
relating to the subject matter of this applic~ion and hereby authorized represaaatives of the City to enter upoq the above-mdttioned property for inspectiwts purposes.
NOTE: The building official may voke a permit on approval issued under the provisions of the 2000 Intemaeiorral Code in cases of any false statement or
misropresenta 'on f fact in the ication 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 ~a~s~
Signature
Do you ~~
to be contacted by fax, email o hone? ircle One
WARNING- BUn.DING P ST BE POSTED ON CON.
Plan fees are non-refundable and are pa[d fu full at the time of application
City of Rezburg's Acceptance of the plan review fa does sot constitute ob
~~ ~3i~
DATE rl,'
.. u
tuarv 1.2005. j
r-
2 ~= 2006
~` 2
E~
'~~~e~S~ COl11~3~~t~ ~~1(' ~I11~ .E~l~)~3~1C~~1~D~~ ti'tt~e a.~uestion clot apply till in ~~r~ ti3r nuu
ap~alis~ablc
NAME
PROPERTY ADDRESS
SUBDIVISION
Permit#
R~~-ui~°~~l!1 ! u~ ~EC~IANICAL
Mechanical Contractor's Name: Q 1. 1~~~`~S Business Name: ~ ~ ~ ~ b
Address ~ i ! ~ ~,~ • 5~C*~ 1 ~ r City ~~~b ~ State ~ ZipC~
Contact Phone: (Z~) 3~r'-- 9'~g 7 Business Phone: ( ) ~ ~3 ' '~~U
Email la-L{='c w/y- ~ ~~ b7 Lf ~. ~[,~ Fax 2a~ ~~Il ~ ~~~
Mechanical Estimate S ~OfX~aw (CommerciaUMulti Family Only)
FIXTU~S & APPLL4NCES CDUNT (Single Family Dwellin Only)
~_ Furnace Exhaust or Vent Ducts
FurnacelAir Conditioner Combo
Heat Pump
Air Conditioner
Evaporative Cooler
Unit Heater
Space Heater
Decorative gas-fired appliance
Incinerator System
Boiler
Pool Heater
~ Dryer Vents
Range Hood Vents
Cook Stove Vents
.3 Bath Fan Vents
other similaz vents & ducts:
Similaz fixtures or Appliances
_ ~~~Tuel Gas Pipe Outlets including stubbed in or future outlets
Inlet Pressure (Meter Supply) PSI
Heat (Circle all that apply) Gas Oil Coal Fireplace Electric
Mechanical Sizing Calculations most be submitted with Plans & Application
Point of Delivery must be shown on plans.
~~ -~' l35
z aG
Signature of l,icenscd Cont'ract~r License numbcl• Date
Requ6reci!
The City of Rexburg's permit fee schedule is the same as required by the State of Idaho