HomeMy WebLinkAboutAPPLICATION - 17-00332 - 248 S 3rd W - Gas LineCITY OF Building Safety Department
BUILDING PERMIT FORM q 1 Q City of Rexburg
°°'a`od'°"°'c 35 North 1St East
America# Family Community Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
Permit Number: ❑ Mechanical Fees Paid
L. Property 0%, er
Dame: ++
Address: (QQ1 Li E City: 4 uSx,l l (e State: _LLL_ Zip Code: �3/ 7
Phone:. R'O i - 317 - '711 q Email: d l a� -
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
E'9o, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: ADlks! iG 4lG State License #: #V0_ - e - 1JY _ Exp.: L%,- J - t_ o20
Address: 4 0 yj S > IN'tcu. City; • . t I State: `Zip Code: V4��
Phone: C33 " - a€1 - 3 7a Email: ,QQ a ,� e�stP,ZQ� —
Contact/Rep. Name: ne: L - 3774 mail: h p u mps ei ecc ae. vtet!
Mechanical Contractor Authorized. Signature, � Z��C Date:
A copy of ;Cur state registration/license is required to be on file. If this is the first time ou have don orlr in the City of Rexburg Ilease rovide
a photocopy ofyour license. Ifyou are unsure 1f your license is on file, please check with the Permi echnician by calling (208) 372-`1341.
1 Project Description
Address: 4q ` `a . _ 3 LkJ -0R- Lot #: _ Block #: _ Subdivision:
What type of Property: Residential ❑ Commercial
Cost of job: $
Description of work: Q -s f iL
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
04"' -Gas Line = $65 o Built-in= $130
I] Water Heater = $65 o Free-standing = $65
❑ Miscellaneous/Requested Inspection = $65
Inspection fees can be bundled upon request Re -inspect fees will be enforced if inspection requests exceed fee totals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that 1 have read this application and state that the information herein
is correct and I swear 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 2012
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.
Applicant's Name (print)- =IZ (t 41-1 Signakur Date: f
Inspections must he called in before SAM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341