HomeMy WebLinkAboutAPPLICATION - 17-00411 - 191 S Millhollow Rd - Landing CoverCITY OF
REXBURG
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Amman Family Community
BUILDING PERMIT FORM1�2
Updzkdla/2015
BUILDING APPLICATION
Single Family Residence Remodel
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
Permit Number: Zoning: Application Fee Paid: O $100
1. Property Owner
Name:t41clW&L OaLA6sIetick� t�
Address: 07 15 . M%L4.il*A aW City: h aryc P,i:i State: Zip Code: A7 �g M44/0
Phone a dIS1 2.1.7 :33 0&J Email: mikhfae~k- / 6. fx e.
Under Idaho Building Code, a homeowner is allowed to do work on their ow home.
Are you a homeowner doing work on your own home?
X -Yes (Skip to #4 and complete the Homeowner's Exemption)
❑ No, I am working with the homeowner
2. Applicant
Name: Role: (Owner, Tenant, Contractor, etc.)
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name:
3. General Contractor
Name: Registration #: Exp.:
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
General Contractor Authorized Signature: Date:
A copy ofyour state registration/license is required to be on ffle. 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.
4. Project Description
Address: )9/ 5. Mf1J.,Ai414ac.d
Project Description: f'loW04' Ow>♦-+sda Sot p4
• Estimated Total Cost: $_.SSaEtA®�l
• Check All Included in Scope of Work:
❑Mechanical Work Cost: $ % ❑Electrical Work Cost: $ ❑ Plumbing Work Cost: $ Z9'
Note: Any contractors involved will need to fill out their respective application.
• Fireplace(s) Being Installed? ❑ Yes §. No
Building Permit fees for remodels are charged based on cost. The application fee applies toward the fee total For details on how fees are
calculated, contact the Building Department. There will also be a plan review fee totaling 1095 of the building permit fee.
APPLICANT'S 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. 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. Permitvoidifnot
started within 180 days. Permit void If work stops for 180 days.
Applicant's Name (print)
Lel
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