HomeMy WebLinkAboutAPPLICATION - 17-00450 - 375 S 5000 W - Furnace & ACCITY OF
IREXI URG BUILDING PERMIT FORM 4� I
Av I
Updated 1012016
Building Safety Department
City of Rexburg
35 North 1St East
Sao Anrerira'sFamily Casmnmiry Rexburg, Idaho 83440
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BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
.Permit Number: ❑Mechanical Fees Paid
1. Property Owner
Name:
Address: w , City: Zip Code,
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 own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
`tgo, I am working with the homeowner
2. Mechanical Contractor
Under Idaho BuildinCode, a registered contractor must do the workfor a Commercial Building.
Business:CS to icens #: n l Exp.:
Address: City: State: Zip Code:
Phone: <,-, Z 7 7 Email:
Contact/Rep. Name: Phone: Email:
Mechanical Contractor Authorized Signature: Date:
A copy ofyour state registration/license is required to be on file. if this is the first time you have done work in the City of Rexbul p, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Tech» ic:cr,l by calling (208) 372-2341.
3. Project Description
Address: -OR- Lot #: _ Block #:*— Subdivision:
What type of Proper4E.esidential ❑ Commercial
Cost of job: $
Description of work:
4. Fees: 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: Under penalty of perjury, i hereby certify that r 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 1 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 lfworkstops for 180days.
1(7 Applicant's Name (print): ��- Signature: 1 Date: .Z
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.rexburgorg Permit Technician -(208) 372.2341
CITY OF
REXBURG
cW
Anterira's Family Commaniq'
BUILDING PERMIT FORM 410
uod,ud 1o/2o1s
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg '
35 North 1St East
Rexburg, Idaho 83440
For Office Use
.Permit Number: .❑ Mechanical Fees Paid
1. Proper ovnmer r r'
Name: U��
1 Fla-
Address: City: State: 7f) Zip Code,�S ,
Ve
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 own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
_Q'o, 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: ( A �'� Stale LI� L� �� Exp.:
Address: City: State: Zip Code: 3
40
Phone: -7 Email:
Contact/Rep. Name: 114 UNMu-G— Phone: Email:
Mechanical Contractor Authorized Signature: Date:
A copy ofyour state registration/license is required to be on file. If this is the fit st time you have done work in the City of Rexbuty, 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 Proop��1 :,�Residential ❑ Commercial
Cost of job: $ j n
Description of work:�� C__
UJ
4. ees: Check all that apply:
Furnace orA/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
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that I have read this application and state that theinformation 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 th er t or approval was based. Permit void if not
started within 180 days. Permit void if workstops for 180 days.
r` __ h
Applicant's Name (print): \b�— 1, Signature: Date: Z�
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 nextbusiness day.
Inspection Hotline- (208) 372.2344 www.rexburgorg Permit Technician -(208) 372.2341
�;C 4EXBtrRc,;
u�a
•�r'+w[o J��
CITY OF
REXBURG
Arneriras Family Connnrmity
BUILDING PERMIT FORM 410
Updrhdl0/2016
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
.Permit Number: ❑ Mechanical Fees Paid
1. Prope • Ownell
Name: OXr; /�
Address: City: � d" ' State:- Zip Code: 3 7 `I
Phone: $2 1 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)
I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registeredcontractormust do the workfor a Commercial Building.
Business: �` -� �J\ State License #: —� ( Exp.:
Address: 4 f- City: ~ �C (�S State: 'T' O Zip Code: Q
Phone: D 2 - 7 7 17 Email:
Contact/Rep. Name: � L- Pho e: Email:
Mechanical Contractor Authorized Signature: >✓ Date: ?
A copy ofyour state registrationflicense is required to be on e. if [Itis is r tr a you lelave done work in the City of Rexbing, please provide
a photocopy ofyoui license. Ifyou are unsure ifyour license i 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:`ErResidentlal ❑ Commercial
Cost of job: $_ �(wAnkrn-�-V0
Description of work:
4. Fees: Check all that apply:
Furnace orA/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
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of pequry, I hereby certify that I have read this application and state that the Information herein
is correct and 1 swear that any information which may hereafter be given by me in hearings before the Planning and Zoning Commissinn or the City Council for the City of Rexburg
shall be truthful and correct. 1 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 tie permit or approval was based. Permitvold Knot
started within 180 days. Permit void if workstops for 180 days.
1.
Applicant's Name (print): �4A�cl' 5� Signature: kb\ J 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 nextbusiness day.
Inspection Hotline -(208) 372.2344 www.rexburgorg Permit Technician -(208) 372.2341