HomeMy WebLinkAboutTEMP ELE SERV APPLICATION - 16-00482 - Campus Courtyard 2 Bldg 8 (21 Units)Oe pexa URC,
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a,� 0 JtE) BURG BUILDING PERMIT FORM 32�
upda•d 10/2016
AmerimSFamily Community
BUILDING APPLICATION
New MFR Electrical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: Electrical Fee Paid)Q
1. Property Owner
Name: 4"eJ �1w•.,•-e�
Address: City: State: Zip Code:
Phone: Email:
2. Electrical Contractor
Under Idaho, Building Code, a registered contractor must do the work for a Multi family Residence.
Business: VL State License #: C-NI1,40 Exp.:
Address: -T? Al• 4d:ns LO. City: � State: Td- Zip Code: $a440
Phone: ?4*'30—M> Email:
Contact/Rep. Name: c Phone: /1¢-3td--ZW Email:
Electrical Contractor Authorized Signature: �/�`/�` Date: « '1 /1
A copy of your state registration/license is required to be on file. If this is the first time you have done work in the City of Rexburg, please provide
a photocopy 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: aG `P S • OR- Lot #: Block #: Subdivision:
Description of work: Tem a Sa✓ g2 -c {
❑ New MFR Construction: # of Buildings: # of Units:
• Fees far new construction are charged by number of buildings and number of units.
o (130x#of buildings) + (65 x # of units) = totalfee Le. (130 x2 buildings) + (65 x 10 total units)=
$260 (buildings) +$650 (units) _ $910 total fgg
• There will also be a plan review fee totaling 1046 of the above fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, thereby certify that l 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. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days.
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Applicant's Name (print): `• - ��w Signature: Date: »t 17
i z
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.rexhurg.org Permit Technician - (208) 372.2341