HomeMy WebLinkAboutAPPLICATION - 17-00246 - 6735 W 5000 N - County MechanicalCITY OF
REXBURG
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Amencai Family Community
BUILDING PERMIT FORM 410
UP&nJ 10/2016
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
1. Propertt}�''
Name: Kv�t $ Yta,u 1
Address: G7 3s W - 5A?O N . City: /�iXdli!ui State: fig.._ Zip Code: 8341 6
Phone: Email: !/ A;' /LbA40($A4,(, W4 PYW,V. C-0 *W
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
ll esNo, I am working with the homeowner
2. Mechanical Contractor
Under Idaho BuildingCode, a registered contractor must do the work fora Commercial Building.
Business::lawt6MA 14 P(uMLA- l:- P7> i state License #: 9Y6-6- 1357 Ex 3/ i
Address: _5(Ik W. 6,wo iy . C Grta State: p
_Zip Code: 93440
Phone: 20 ^ ! 3 Email: 77,4 C1viltir'/. ce,,<
Contact/Rep. Name: ' Phone: 313-3313A Email: 4w t Ili q 7740 et�r'/,
Mechanical Contractor Authorized Signature: /G�1/,� �-��—� Date: to /
A copy ofyour state registration/license is required to be on file. If this is the first tirne you have done work in the City of Rexburg please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the permit Technician by calling (208) 372-2341.
3. Project Description
Address: 6 35_W • S600n1 . -OR- Lot #:_ Block #:_Subdivision:
What type of Property: ITIesidential ❑Commercial
Cost of job:$ /
Description of work: Fe" IIAfke_ (1�r�1,te� ui1 `ritE-PLA. -'-e-
4. Fees: Check all that apply: tt
Furnace orA/C =$65 Fireplace/Solid Fuel Burning Unit:
Gas Line= $65 o Built-in = $130
❑ Water Heater = $65 // .�( 0,,. Free-standing = $65
' W _F` Miscellaneous Requested Inspection = $65
3 �xdtl�wyf �ayst ILa%rr�..0 l,'
Inspection fees con be bundled upon request Re -inspect fees will be enforced if inspection requests exceed fee totals.
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, l 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 me In hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct 1 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 far 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 Knot
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print):. • Ct% t �JA'"t'S Signature: �u9l�Gt�' c Date: w /7