HomeMy WebLinkAboutAPPLICATION - 17-00134 - 232 E 5th S - Furnace & ACC I TY OF
REXBURG
BUILDING PERMIT FORM 410
Updated 10/2016
Building Safety Department
City of Rexburg
35 North 1St East
Americas Family Community Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Proper Ow I er
Name:
Address: S City: State: �_ Zip Code: 3 �l
Phone: Z09,- ' 7-3 3 Z 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)
moo, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Buildling Code, a registered contractor must do the work for a Commercial Building.
Business: l (r`b i—,��S� e'� State Ll1icen�se #:yG-�— L� Exp.:
Address: u �L City: �a VAC `V -r State: i Zip Code: 3
Phone: - -17 2 7 Email:
Contact/Rep. Name: Phone: Email:
Mechanical 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 file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: 2.3 Z C 5 F h S -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: IPtesidential ❑ Commercial
Cost of job: $-
Description of wo 04kL
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
❑ Gas Line = $65 o Built-in= $130
❑ Water Heater = $65 o Free-standing = $65
❑ Miscellaneous/Requested Inspection = $65
Inspection fees can be bundled upon request Re -inspect fees will be enforced if inspection requests exceed fee totals
APPLICANT'S 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 mein 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 for 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 fal
started within 180 days. Permit void
Applicant's Name (print):
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