HomeMy WebLinkAboutAPPLICATION - 17-00508 - 160 W 5th S - Autumn Winds - Dryer Vents°s asneuec,
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Amerums Family Community
BUILDING PERMIT FORM 410
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1st East
RexburE. Idaho 83440
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Property Owner
Name:rjt
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Address: City: l6 State: ! Zi Code:
Phone: t -7' Email:
Under Idaho Building Code, a homeowner is allowed to do work on their di 1 home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to section 4 of this application and complete the Homeowner's Exemption page as well)
No, I am working with the homeowner
2. Mechanical Contractor
Under Idaho B
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r/di
ng Code, a registered contractor must do the work for a Commercial Building.
Business: T ' { J < LLL Sz ite License #: ✓C -t () Exp.:
Address: 2 L3)2- Lal . City: State: f Zip Code: y_
Phone: V Email: �l(�sh�trGq/y1t�l�,
Contact/Rep. Name: _ 91A rl. Ph e: /"V_Email:
Mechanical Contractor Authorized Signature: Date: Z
A copy ofyour state registration/license is required to be on file. If this is t�first timeyou have done workin the Cityof 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.
3. Project D ' tloq -A
Address: if VV GW✓ 1 OR- Lot #: _Block #: _Subdivision:
What type of Property: 13 Residential 3j'Commercial
Cost of job: $ Q. 60 /
Description of work: k�5
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-inspectfees will be enforced if inspection requests exceed fee totals.
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. 1 agree to comply withal] 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 cases of any false statement or misrepresentation of fact in the application or on the plans o which[ per mit or approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): 6 'RW fnul W0' Signature: Date: ZZ
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 - (2 08) 372.2344 www.rexburg.org Permit Technician - (208) 3 72.2 341