HomeMy WebLinkAboutAPPLICATION - 17-00376 - 4820 S 4300 W - AC & Furnace ReplaceCITY OF Building Safety Department
REXBURG BUILDING PERMIT FORM 410 City of Rexburg
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BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
.Permit Number:
❑ Mechanical Fees Paid
1. Properweer
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Name:
Address:
City: ' . V a State: Y Zip Code:
Phone: `5 Sin --9 D X46
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)
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: C
State License #: (QCExp.:
—=
Address:
City: 22 State: Zip Code:
Phone:
Email:
Contact/Rep. Name:PAAA,
2
Poe: C7al
Mechanical Contractor Authorized Signature:
di. Date:
A copy ofyour state registration/license is required to be on
e. If tids-is the fit st time you have done tvork in the City of Rexbitiv, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technic Ant by calling (208) 372-2341.
3. Project Description
Address: -OR-
Lot #: _ Block #:*— Subdivision:
What type of Property -4e -Residential ❑ Commercial
Cost of job: $, ,LTJ
Description of work:
4. Fees: Check all that apply:
❑ Furnace orA/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 -inspect fees will be enforced if inspection requests exceed fee totals
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, 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 Commissinn 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 ofany false statement or misrepresentation of fact in the application or on the plans onwhich the pe it or approval was based. Permitvoid if not
started within 180 days. Permitvoldifworkstopsfor 180days.
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Applicant's Name (print):�AO�k6—' Aa Signature: Date:
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 nextbusiness day.
Inspection Hotline- (208) 372.2344 www.rexburg.org Permit Technician -(208) 372.2341