HomeMy WebLinkAboutAPPLICATION - 17-00249 - 81 1-2 W 4557 N - Gas liner4 CITY 6P
REXBUI
AmeHmir Fol iii cor-
For Oflic 0'se
Building Safety Department
BUILDING PERMIT FOR q 1 Q City of Rexburg
Updated 14/2016 35 North 1st East
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechaniccil Work
Permit Number: - r
`.tilechan.(; ill .'.4 Pa.1d.
-- Y i;
1. 1'l cpert O��ner
Name: �.
Address:
Phone:
Under Idaho Building Code, a hoi
Are you a homeowner doing work
❑ Yes (Skip to #14 and con
L�3'No, I am working with t
Z. Mechanical Contractor
Under Idaho Building Code, a reg
Business: - +nGts l
Address:(
Phone:
Contact/Rep. Name:
IV City: _Tjg [
Email:
owner is allowed to do work on i
your own home?
etc the Homeowner's Exemption)
homeowner
contractor mustdo the work
State Lic
City: Sid
Email:
Phone: (P -4 -
State: Jd Zip Code: Z VVQ
own home.
r a Commercial Building,
9:.l-LUC_6 - /1 Exp,:�2 �o241d'
Stater Zip Code: _2-3 _
;'
A copy of your state. regrsti•otron/license i required to be on cle. I 'this rs the t rim r Date:
/ } you have done work in th City of Rexburg, please provic
a photo copy ofyour ldcerise. Ifyou are un ure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: & rd 2A �,iII & .OR- Lot #; _ Block #: — Subdivision:
What type of Property: ❑ Residential 011commercial
Cost of job: $ a(10 c`
Description of work:
4. Fees: Check all that apply:
❑ Furnace orA/C = $65
P ---Cas Line = $65
❑ Water Heater = $65
Inspection fees con be bundled upon
❑ Fireplace/Solid Fuel Burning Unit:
o Built-in = $130
o Free-standing = $65
❑ Mis ellaneous/Requested Inspection = $65
Re-inspectfees will be enforced if inspection requests exceed fee totals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty olperjury, I hereby certify that 1 have read this application and state that the information herein
is correct and I swear thatany 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 al City regulations and State laws relating to the subject matter of this application and hereby authorized represerstatives of the
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official mayrevoke a permit on approval issued under the provisions t the s of t
International Cade in cases of any false statement or misrepresentation of fact in the application or on the pl ns on which the permit or approval was based. Permitvoid if not
started within 180 days. Permit void if work stops for 180 days,
Applicant's Name (print): L� g � Signature: t - (Y - I e - Date:.�
I ft
Inspections must be called in before 8 AM on he day the inspection is requested. Inspection requestk called in after SAM will be scheduled for the next business day.
Inspection Hotline- (208) 372.2344 www.rexhurg.org
Permit Technician - (208) 372.2341