HomeMy WebLinkAboutAPPLICATION - 17-00498 - 330 N 12th W #12 - Gas LineO� R�tr$C
CITY OF Building Safety Department
BIMV LAG BUILDING PERMIT FORM 1 City of Rexburg
tom, Updated TO/2016 35 North 1St East
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Rexburg, Idaho 83444
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office ' iso
Permit Number:
❑ Mechanical Fees Paid
L Property fawner
Name: J '
Address: Cip�{�Q
State: _�%� Zi Code:
Phone: 7Lce�P la✓t Email: _fir' h Lr i"AGr
Under Idaho Building code, a homeowner is allowed to do ti ork on their own home.
Are youu a homeowner doing work on your own home?
❑ Yes (Skip to i#4 and complete the Homeowner's Exemption)
No, 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: Z State License #: Ex �Q /
r P:
Address: City: I State: _.� Zip Code:
Phone; Qf
o`llfi- 1c2��I - ' Email:
Contact/Rep. Name: t hone: - a - 7 mail:
42-014
Mechanical GvntractorAutl q bed Signature. Date:/
A copy of your state r rllstrutit rn/license is • equi red to be on file. If this is the first tim you have do Orli it, the City ofh'exbury, please provide
a photo copy ofyour license. Ifyou are unsure if your license is on file, please checkwith the Perniit Technician by calling (2 08) 372-2341.
3. Project Description �
Address: 3,3 0 n . !a —. LJ -0- ' -OR_ Lot # Block #; _ Subdivision.
What type of Property: 0 Residential ❑ Commercial
Cost of job: $
Description of work:
4. Foes: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
P' --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 I 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 ofthe 2012
International Code in eases of any 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 if work stops for 180 days.
Applicant's Name (print): . r Signature uC. Date: SI-/!�7
Inspections must be called in before 8 AM an the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - CZ08) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341