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BUILDING PERMIT FORM'
Updated 10/2016
M 1
BUILDING APPLICATION
Comri7ercial Electrical
Building Safety Department
City of Rexburg
4 35 North 1St East
Rexburg, Idaho 83440
For Office UseMI.
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Permit
Number: .. .......Electri cal Fees Paid. -O''
............ ..
. .. .. .....
....... ... .......
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1. Proper Owner
Name: ��IS1
Address: l��rz�'��i l,l!�LLti;tti�' CLk� �% �'`�� cily: LL'`��"►'�1�� State:C..R—Zip Code: ��_�_
Phone: Email:
2. Electrical Contractor
Under Idaho Building Code, a regz*stered contractor m ast do the work for a Commercialf1Building. 713 Business: � ` _StateLicense .3 rZ- C Exp.:
Address: %/� G�Le ''lily 1� • City:, ' ' i ,�_ State:.,�� Zip Code:
Phone: �.� �I - 'T i �I J. _ Email: l s 1,'%ft' V"Y' � S i r'L� L e 1. �_' i`''' dcL C�U M
Contact/Rep. Name: �^� k L L��
Phone -i ����1 • (`s:�'i.�_ Email:
Electricalr'"Contr'..''actor.--.,Aut
horized Signature ; ��' 1 ' ��--� --- — Date.
A copy ofyour state registration/license is required to b e on file. `f this is the first timeyou have done work in the city of Rexburg, please provide
a p hoto copy ofyour license. ifyou are unsure ifyour license is or+ file, Tease check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address. � `f � � � � �� � ' ��Y44W-:13LoLi�
Description of work:f� t40
Project Cost: $ _ toL����� • �Y kT0L`Tc:4`
Feesfor commercial projects are charged by cost:
o First $10, 0D0 = 2 % + $6 0. From $10, 00 0 � o $1 00, 000 = 1 Vo + $2 6 0. A bove $100, 00 0 = .5% +$1, 1 60. i.e. Work costing
$IS,DOO will be charged $260for thefirsf.$10,000 and 1 910 of the remaining $5,000 = $260 + $50 =S310 total fee
There will also be a plan review fee totaling 10% of the above fee.
APPLICANT'S SIGNATURE,CERTIFICATION i� ���I��N: Under penali.y of Perjury, I hereby certify that I have read this appHication
fter be given by Council for the City -of �r
is correct and I swear that any information which may hereae o e ril before the Planning and n�
et I r t comply with all City regulations and Sty
relatinglaws application .gid here authorized representatives f the
shall be truthful and T lhbuilding official r rpermitissu ed
City to enter upon theab-mentioned �property ��������
he plans on which the permit or approval was based. Perinit '�� if not
in r �`nttin f fact 'n i.h application r on tInternational Code eases of any statement r �
started within 184 days. Permit void if workstops for 7.80 days.
Applicant's Name (print):
ye:
ture:
Inspections must be called in before 8 AM on the day the inspection is requested. inspection requests called in after 8 AM
Inspection Hotline-- (20S) 372.2344 vvww.rexhurg.org
will be scbeduledforthen t business day.
Perm -it Technii n- 72.2341