HomeMy WebLinkAboutAPPLICATION - 17-00224 - 4232 W 1000 N - Gas LineBuilding Safety Department
CITY Of City of Rexburg
7� �XBIMG BUILDING PERMIT FORM 410
1� „a,a 35 North 151 East
em
America} Family Community Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use ❑ Mechanical Fees Paid
Permit Number:
1. Property Owner 9s "l C� C
Name: 6— 1 ,p State: �� Zip Code: O ✓�
Address: 'L1 Ul ltd /h% City:
Phone: tt
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 honte?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: i�7 State License #: j_Exp.:
Address: 0 X �O1 ity: State: Zip Code:
Phone:
Contact/Rep. Name:
Phone:
Email:
Email:
Date:
Mechanical Contractor Authorized Signature.
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 F
a photocopy ofyour license. If you are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
,..IIII OR- Lot #: _Block #: _Subdivision:
Address:
What type of Property: ytResidential ❑ Commercial
Cost of job: $—
/' \\
Description of work:
4. Fees: Check all that apply: r" n I
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
O `) 2�)� o Built-in=$130
Gas Line = $65 MAY o Free-standing = $65
❑ Water Heater=$65 Rexburg �f Rf� ❑ 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 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 me in hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct Iagree to comply with all City regulations and state laws relating to the subject matter of this application and hereby authorized representatives ofthe
2012
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official may revoa which the permiton oval issued under the provisions voof id
of
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 ifwork stops for 180 days. r
Iffa
Applicant's Name (print):
t V Signature: _ Dater
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be schedPuled for Technician the next business
372.2341
Inspection Hotline - (208) 372.2344 w,w.rexburiforg