HomeMy WebLinkAboutAPPLICATION - 17-00523 - 10 1/2 E Main St - Mechanical WorkOY �P'7t➢Ut?C
C, I v Y 0 V. Building Safety Department
nXBURGBUILDING PERMIT FORM 41 City of Rexburg
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Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
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Permit Number:
l.a;tical 1-ces, Paid
1. Froperty Owner — ,
Name: YY\etf
Address: aWY t Ci
Phone: - ( �5C73 State:. C Zip Code: l3�
Email:
Underldaho ,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)
M --No, I am working with the homeowner
Z. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the workfor a Commercial Building.
Business: -ri,nLti5 !` Ll1YVl S State License #:G -
Address:() '�C� C' S Vl'� [u ,L. / Exp.:(j d'
City: S State:. l� Zip Code: �3
Phone: �f�R'-Cr,acl - _3 -7 Email:
Contact/Rep, Name:
Phone: �7 - mail:
ari�cal Ccitila p,,'.1
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A co a ' our state r e rstf atron license is required to be on file. If this is the first tlnr you have done rk in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou erre unsure ifyour license is on file, please checic with the Permit chnlcian by calliRq (208j .372 2341.
3. Project Description
Address: J �1 yj� _ -OR. Lot #; _ Block #: , Subdivision:
What type of Property: ® Residential C] Commercial
Cost of job: $
Description of work:
4. Dees: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit;
M__ -Gas Line = $65 o Built-in = $130
❑ Water Heater = $65 o Free-standing = $65
��/} '�M" iscellanea� use Regtrested inspection = $65
Inspection fees can be bundled upon request. , e-inspectfees will be enforced ifinspec ton requests exceed fee totals.
APP1dCAWS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that 1 have read this application and state that the information herein
is correct and I swear that any information which may hereafter be given by mein 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 the permit or approval was based. Permit void if not
started within 180 days. Permit void If work stops for 18o days.
Applicant's Name (print): Signatur J8 T
Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after SAM will be scheduled for the next business day.
Inspection Hotline- (208) 372.2344
www.rexburg.org Permit Technician - (208) 372.2341