HomeMy WebLinkAboutAPPLICATION - 17-00034 - 795 S 5th W - Meter Base ChangeC I TY OF
REXBURG
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BUILDING PERMIT FORM 420
updated 1012016
BUILDING APPLICATION
Miscellaneous Electrical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: �7,0003��
/
� Electrical Fees Paid
1. Property Ow�n^er .,O
Name: t_!J
Address: W,5 ,5d-Lc�Gt, <J7X 4(la City:.
State: L/� Zip Code:
Phone:dZZ- -35G -63 i;,Z
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)
1F7 N0, l am working with the homeowner
2. Electrical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: �e
State License #: Exp.: 515oli 7
Address: q!V,2 S y f City:
State: ��� Zip Code: O
Phone: 020,8- 3 SCP - 37,7e)
mail: / i 5 uu";, /fP o�
Contact/Rep. Name: Phone:
Email:
Electrical Contractor Authorized Signature:
!//Ji[ Date:o?%/ 7%/ 7
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. lfyou are unsure ifyour license is on file, please check with the Perin tTechnician by calling (208) 372-2341.
3. Project Description
Address: 5a"Lo. o n (/y p( (/ OR Lot
#: _ Block #: _ Subdivision:
What type of Property: "esidential ❑ Commercial
Cost of job: $—'5Lao '
Description of work:
4. Fees: Check all that apply:
❑ Central Heating/Cooling Systems= $65
❑ Pumps - Water, Irrigation, Sewage (per motor)
❑ Temporary Electrical Services ONLY = $65 (200 amp
o $65 - up to 25HP
or less. One location, for less than 1 year.)
o $95 - 26- 200HP
2� New Circuits = $(65 + ($10 x # of branch circuits))
o $130 - over 200HP
$
❑ Spas, Hot Tubs, and Swimming Pools = $65
❑ Miscellaneous/Requested Inspection = $65
❑ Temporary Amusement = $65 + $10 per ride,
❑ Generators = $65
concession, or generator $
❑ Irrigation Machine = $65 for center pivot+ $10 per
Inspection fees can be bundled upon request Re -inspect fees will be
tower or drive motor = $
enforced if inspection requests exceed fee totals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that l have read this application and state that the infurmadan herein
I$ correct and 1 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. 1 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 Cade in cases of any false statement or misrepresentation of fact in the application or on the plans an which the permit or approval was based Permit void if net
started within 180 days. Permit void if work stops for 180 /�K _"a7days. /�
Applicant's Name (print): 91- A/ f'l✓I1an Signature:e�4/'le Date: I-02' 7
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