HomeMy WebLinkAboutAPPLICATION - 17-00098 - 5431 S 1650 W - County FireplaceCITY OF
REXBURG
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Amerlais Family Community
BUILDING PERMIT FORM 410
Updated l0/2016
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 11t East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Property Owner
Name: u )(0 A-/ ! c, J0 D
Address: City: IZ�x6df� State: Zip Code: C%
Phone: Email'
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your awn home?
❑ Yes (Skip to #4 and complete the Homweowner's Exemption)
No, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building, G
Business: A — / S 7b V10 _ ! r ✓��o�k State License #: f LIL, -'C— /04 S Exp.:` +V3 r /J
:Address: Z06),5 City: ' Q%h o �( State: ID Zip Code: O .?L j
Phone: 2—Oh'— � 2-7 2-0 Email:
Contact/Rep. Name: <G 9,✓ 7— W e SSeL J�hone:
Mechmai
_ anical Contractor Authorized<L
. Signature, `' Date'3- Y-1
A copy ofyourstate 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: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 o Built-in = $130
❑ Gas Line = $65 o Free-standing = $65
❑ Water Heater = $65 ❑ Miscellaneous/Requested Inspection = $65
❑ Fireplace/Solid Fuel Burning Unit:
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 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 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 false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void Your
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print):
Signature:
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 - (2 08) 372.2341