HomeMy WebLinkAboutAPPLICATION - 17-00109 - 370 S 5th E - Furnace Upgrade*tx"°R` CITY OF Building Safety Department, ra
7QCity of Rexburg
REXBURG BUILDING PERMIT FORM 410
h, UDdaud10f2016 35 North 1St East
Amtriwi ramily Community Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Property Owner
Name: i%y,n free.
Address: _ 370 ..s City-. AWLI, s State:.�f Zip Code: Fay°ra
Phone: 208 -2-01- 3dcTx' 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)
[ZNo, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: �.k 'ageW lIecic,� r.c/ State License #: !?672y Exp.: Z�3(1
Address: /'v 13vr City: fRr s6.' State: Jo/ Zip Code: 2",Yy.?
Phone: ?08— 7YS 90 Email:
Contact/Rep. Name: Phone: Email: -z-xa.x ,acv
Mechanical Contractor Authorized Signature: _/4 Date: 31`/ r
A copy ofyour state registration/license is required to be on file. If this is the first timeyou have done work in the Cityof Rexburg, please provide
a photo copy 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
Address: 37-0 S f -OR- Lot #: _ Block #; _ Subdivision:
What type of Property: El Residential 0 Commercial
Cost of job: $ 3do
Description of work:«
4. Fees: Check all that apply:
K 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-inspectfees 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 I 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 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): 1,01901d -r11gfiG'o49D Signature: ZZ' Date:
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