HomeMy WebLinkAboutAPPLICATION - 17-00369 - 2136 Ferris Ln - AC InstallCITY Of
REXBURG
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Amerim3 family Community
BUILDING PERMIT FORM 410
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BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Mechanical Fees Paid
I. Prop �{ty Owner
Name:.,1�,,,
Address,)�`(� �yf\_ LYl City: State: 7— Zip Code: Rsq/ 10
Phone: �n�i 7]7-244 Email: (- Ed({'7kbM ) COM
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)
o, 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: ` tate License #: Exp.: 10/17
Address: Ci Klabi i State: Zip Code:
Phone: al .
Contact/Rep. Name: � Phone: �f'�-%u5'Q Email: (AYYY)dS iYY1iIem-
Mechanical Contractor Authorized Signature: Date: 17 00
I 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 provid+
U photocopy ofyour license. Ifyou are unsure ifyour license is onFle, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: _` ��(t Fit r13 l� -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $ t4101
Description of work: RC, l(Ish l l
4. Fees: Check all that apply:
Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
❑ Gas Line = $65 o Built-in = $130
❑ Water Heater = $65 o Free-standing = $65
❑ Miscellaneous/Requested Inspection = $65
Inspection fees can be bundled upon request Re-inspectfees will be enforced if inspection requests exceed fee totals.
APPLICANTS 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 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 ofthe
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
smtted within 180 days. Permit void iffwworrk stops for 180 days.
Applicants Name (print): Cil (\Q )6& k) Signat reNN
Date: 7/f�Q
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