HomeMy WebLinkAboutAPPLICATION - 17-00385 - 114 Elm Ave - Egress WindowCITY OF
REXBURG
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Amerka} Family Community
BUILDING PERMIT FORM 104
uea.md 1012016
BUILDING APPLICATION
Single Family Residence Basement Finish
Building Safety Department
' City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use '
Permit Number: Application Fee Paid: ❑ $100
1. Property Owner
Name: –1-1, c J—I ICA–
Address: I l t f elm City: `c 6 u State: Zip Code:
Phone: S q- 7 k b S Email:
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
❑ No, I am working with the homeowner
2. Applicant
Name: Role: (Owner, Tenant, Contractor, etc.)
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name:
3. General Contractor
Name: C ,�_ S c- Registration #: RCS ' -7 7 "1 Exp.:
Address: 242't 0 S 1nr,l[ow5 o e City: UAh) wlc State: LQ. Zip Code: R2, Y6
Phone: 208- SZ`$ - FrD7 D Email: ylC-.,. R- C_ 1<s IAgIk�o • co &I
Contact/Rep. Name: ale r Ih'I A, a -t.-\ Phone: 4 $/ - 5Y2. Email:
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General Contractor Authorized Signature: 7J0 W\Pc Date: ?-/2--1 7
A copy ofyour state registration/license is required to be on/tle. If this is the first time you 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.
4. Project Description
Address:
Project Description:
• Square Footage being Finished: sq. ft.
• Check All Included in Scope of Work:
❑ Mechanical Work ❑ Electrical Work ❑ Plumbing Work
Note: Any contractors involved will need to fill out their respective application.
• Fireplace(s) Being Installed? Cl Yes ❑ No
Building Permit fees for new homes are charged based on square footage and the City's estimated valuation. For details on how fees are calculated,
contact the Building Department There will also be a plan review fee totaling 10% of the building permit fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby 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 mein 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 withal] 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 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. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days.
Applicants Name (print): Glc ✓1 WI A, 41 r Signature: Lgut/ 1Date:
�— -2"I�-17
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.rexburgorg Permit Technician - (208) 372.2341