HomeMy WebLinkAboutAPPLICATION ELECTRICAL - 17-00158 - 52 College Ave - Tenant ImprovementCITY OF
REXBURG
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America's Family Community
BUILDING PERMIT FORM 420
updated z/Eal]
BUILDING APPLICATION
Miscellaneous Electrical Work
Building Safety Department
City of Rexburg
35 North 15t East
Rexburg, Idaho 83440
For Office Use
Permit Number:
Electrical Fees Paid
1. Property Owner
AP-IrA) &W-1-rS
Name:
Address: City:
State: 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 section 4 of this application and complete
the Homeowner's Exemption page as well)
❑ No, l am working with the homeowner
2. Electrical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: LES N JFL
State License #: 357-11 Exp.:
Address: City:
State: Zip Code:
Phone:
Email:
Contact/Rep. Name: Phone:
Email:
Electrical Contractor Authorized Signature:
Date:
A copy ofyour state registration/license is required to b�his is the first timeyou have done work in the City of Rexburg, please provide
a photocopy of your license. If you are unsure ifyour license is on file,
please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: _'2% / �OFT7¢ ZND EAST -OR- Lot
#: Block #: Subdivision:
What type of Property: ❑ ResidentialCommercial
Cost of job:$ OQ�
'I
Description of work: UO �aE'/✓E2h10�
4. Fees: Check all that apply:
❑ Central Heating/Cooling Systems = $65
❑ Pumps - Water, Irrigation, Sewage (per motor)
❑ Temporary Electrical Services ONLY = $65 (200 amp
o $65 - up to 25HP
or less. One location, for less than 1 year.)
o $95 - 26- 200HP
❑ New Circuits = $(65 + ($10 x # of branch circuits))
o $130 - over 200HP
$
❑ Spas, Hot Tubs, and Swimming Pools = $65
❑ Miscellaneous/Requested Inspection = $65
❑ Temporary Amusement = $65 + $10 per ride,
❑ Generators = $65
concession, or generator $
❑ Irrigation Machine = $65 for center pivot+ $10 per
Inspection fees can be bundled upon request. Re -inspect fees will be
tower or drive motor = $
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 l 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 ofthe 2012
International Code in cases ofany false statement or misrepresentation offact 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 1180 days.
Applicant's Name (print): Rye LE15 MANI Signature: Date: 'g-2-8-17
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.rexburg.org Permit Technician - (208) 3 72.2 341