HomeMy WebLinkAboutAPPLICATION - 16-00767 - Upper Valley ENT - Furnace, AC, Fire Wall RepairsOx pM.%BUBB C I TY OF Building Safety Department
` REXBURG BUILDING PERMIT FORM 410 City of Rexburg
unmtmlo/tots 3$ North list East
r ABmncas roily Conuounity
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office. Use
Permit Number: (G--.767 ❑ Mechanical Fees Paid
1. Proper _tY Owner
Name: UPPER VALLEY EAR NOSE & THROAT
Address: 256 N. 2ND EAST City: REXBURG State: IDAHO Zip Code: 83440
Phone: 208-656-9646 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 ill- and complete the Homeowner's Exemption)
CENo, l am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: MECHAM AUTOMATION LLC State License#: HVC-C-5365 Exp; 10/31/2017
Address: 532 W. HWY 39 City: BLACKFOOT State: IDAHO Zip Code: 83221
Phone: 208-684-7052 - Email: APOMECHAMAUTOMATION.COM
Contact/Rep.Name: CATHY BROWER Phone: 208-684-7052 Email: apOmechamautomation.com
MechanicalContractor Authorized Signature: Date: 11/15/16
A copy ofyour state registration/license is required to on)tle. Iftistheflrst timeyou have done work to the City of Rexburg, please provide
a photo copy ofyour llcense. Ifyou are unsure if your license is on file; lease check with the Permit Technician by calling(208)372-2341.
3. Project Description
Address: 256 N. 2nd East, Rexburg -OR- Lot #:_ Block #: Subdivision:
What type of Property: O Residential [Mommercial
Costofjob: $. 14,48 .50
Description of work: installation of new furnace and A/C unit in clinic and fire wall repairs
4. Fetes: 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: tinder 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 mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall he truthful and correct. I agree to comply with all City regulations and State laws relating to thesublect matter of this application and hereby authorized representatives of the
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building omcial may revoke a permit on approval issued ander the provisions of the 2012
International Code in cam ofany false statement ar misrepresentanon 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): CATHY BROWER
Date: 11/15/2016
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.mburg.org Permit Technician- (208) 372.2341