HomeMy WebLinkAboutAPPLICATION - 17-00456 - 268 W 1st S - Gas Line & Water HeaterDEC -20-2005 01:23
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BUILDING PERMIT FORM 410
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Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
Permit Number:
❑ Mechanical Fees Paid
1. Proper V Owner
Name:
Address: 2&Kso w ,rao7
Phone: City: R�State; �—Zip Code:owo
�20B R512r Email: m,S
Under ldaho Building Code, a homeowner Is allowed to do work on their own home,
Are you a homeowner doing work on your own home?
j(Yes (Skip to #4 and complete the Homeowners Exemption)
❑ No, I am.working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work fora Commercial Building.
Business: State License #: Exp
Address:"
City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
Mechanical Contractor Authorized Signature:
Date;
A copy ofyour state registration/license is required to be on file. /fthis is the first timeyou have done work in the Ci o Rgexbur ,
a photocopy of your license. Ifyou are unsure Ifyour license is on file please check with the permit Technician b calling (ZOBJ please provid
Y 372-2347,
3. Project Description
Address: OR. Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential O 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 = $6S 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, Ihereby certify that l have read this oppilation and state that the Information herein
is Correa and I swear that any Information which may hereafter be given by me in hearings before the Planning and Zoning Commission or the City County for the City of Rood urg
shallbeuut rNlendcorrect I ayroe to comply with aH City raguletions and Stare lawn relating in the subject outer ofthus epPIIoQon and herebyauthorized representatives orthe
City enter upon the above•1110ndoned property for lnapootions purposes. NOTE: The building omtlol may revoke a permit on approval issued under the provisions afthe 2012
lmcmational Code in cases bratty false statement or m3represontadon of ran in the applinunn or on the plant on which the parmit or appruval was based. Permitvmdlrnot
scstadw1thln180days. Permit void if Work stops for 180 days.
Applicants Name (print): Signature: & J �tAkdryn
Date: ZDI
Inspections must be called In beibte 8 AM on the day the Inspection is requested. lnspealon requests called in after is AM will be scheduled for the Hest business day.
InsPacdon Hotilne-(208)372.2344 www.resburg.ora a __ _
TOTAL P.al