HomeMy WebLinkAboutAPPLICATION - 17-00334 - 2261 N 6000 W - County MechanicalCITY OF
REXBURG
CW_
America's Family Community
BUILDING PERMIT FORM 410
Updaod 10/2016
BUILDING APPLICATION
Miscellaneous Mechanical Work
Buildin,g Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Property wrier I��� �
Name: 191CQ -) IytU� -,,
Address: ZZfo I N foaoo vJ City: State: Zip Code: tiS0 fncf�U
.�
Phone: 356 Email:
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)
No, I am working with the homeowner
2. Mechanical Contractor
Under IdahoBuildingCode,kIa registered contractor must do the worfor a Commercial Building.
Business: f(�oy,, 'Hi,6 State License #: `( 16 Exp.:
Address:City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Ph ne: Email:
Mechanical Contractor Authorized Signature: /r Date47��(
A copy ofyour state registration/license is required to be on file. If this is the first timeyou have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
4. Fees: Check all that apply:
'Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
❑ Gas Line = $65 o Built-in = $130
Cl Water Heater = $65 o Free-standing = $65
❑ Miscellaneous/Requested Inspection = $65
Inspection fees can be bundled upon request. Re -inspect fees will be enforced ifinspection requests exceed fee totals.
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 swear that any information which may hereafter he 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 -
Citytoenterupontheabove-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions ofthe 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. Permitvoldifnot
started within 180 days. Permit void ifwork stops for 180 days. I
fJ Si nature. Date: VL-e—��L—
Applicant's Name (print): t g
Inspections must be called in before 8 AM 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
r.
CITY (IF REKHRG
PAID BY: REXURG P� jj-MBTNG A11B FIEATIN3
JAPE; 06/21/1'7 1!A /OLUINFRI.
TIME: 14f13:35 RECEIPT 1-10; 461-106
REF- Nf)c 20126
104 BP MECH. PERMIT UNDER 611, . DO
CHECK A I TUO,"
PAYMENT 55.00
CHANGIF FJO
ILIA
HANK YQUI (,,ME] HA"' A NICE DAY