HomeMy WebLinkAboutAPPLICATION ELECTRICAL - 17-00107 - 523 Edith Cir - RemodelC IT Y OF
REXBURG
America's Runify Community
BUILDING PERMIT FORM 121
u,d.e.d 102016
BUILDING APPLICATION
Remodel SFR Electrical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Electrical Fee Paid
1. PropertX Owner
Name: 14,44L" 4- 5u11`2 Ev&�h 83�
Address: C11/ City: r5 State: Tb Zi Code: '1�6
Phone: 0`�0$" %I S' Y yf Email:_ 40-%� rtix; l.,inf-- dOc�3 e(nl,-ar,Ca
Under Idaho Building Code, a homeowner is allowed to do work on their own home. T
Are you a homeowner doing work on your own home?
,Yes (Skip to 43 and complete the Homeowner's Exemption)
❑ No, I am working with the homeowner
2. Electrical Contractor
Business: State License #: Exp.:
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
Electrical Contractor Authorized Signature: Date:
A copy ofyour 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 photo copy ofyour license. Ifyou are unsure ifyour license is on fie, please check with the Permit Technician by calling (208) 372-2341.
3, Project Desipt�Ipn L
Address: �f SS nfwA Cit • LL'�, � ee s 11 {� {,
Description of work: �an Ii51. u�r( IAI''7L21+�/)f �'V luq e'eG�Y)`(q( tlay n --f 1y 6�raovlS
XRemoclel Cost: $ boo ARA/L°ltitp✓t�"1 �',zp✓1�e}.n C--kll
• Feesfor remodels are charge by cost: ItYt1ou2 C�i �f� e%WYI laI
o First $10,000=29/16+$60. From $10,000to$100,000=1%+$260.Above $100,000=.5%+$1,160. i.e.Workcosting
$15,000 will be charged $260 for the first $10,000 and I% of the remaining $5,000 = $260 + $50 = $310 total
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 ofthis application and hereby authorized representatives afthe
City to enter upon the above-mensIaned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions ofthe 2012
International Code in cases ofany 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
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): at J,��Signature: /1- Date:3//y // 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.rexburg.org Permit Technician - (208) 372.2341