HomeMy WebLinkAboutAPPLICATION - 17-00546 - 340 N 12th W #22 - Gas LineU v'' Building Safety Department
RXA BUR
G: BUILDING PERMIT FORM 410 City of Rexburg
Updated 10/2016 3 North 1St East
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Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
PernaitNumber:
' Mechanical Feespaj
1., Property U�1ler
Dame: Q l
Address:
Phone: -,� _ Cy ' State: T Zip Code:
Email: L
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?
❑ Yees (Skip to #4 and complete the Homeowner's Exemption)
9Y -No, I am working with the homeowner
2. Mechanical Contractor
Under Idaho, 'JBuilding Code, a registered contractor must do the work for a Commercial Building,
Business: �-- 6L15 1 TiL'Wl r,,_ � _ /f�
State License #: Fes!(- ( .Exp.: 2
Address: LJ C S Ci Lv� city:SrL.
State:
" — Zip Code: d3
Phone: _;2[�R'- Cna� -- �
Contact/Rep. Name: Email:
Phone; �
Email:
Date:
A copy ofyour state r egrstrutronJlicense is required to be nn file. If'this
is the first timeynu have done work in the City of Rexburg, please provide
a pFroto copy ofyour lieerrse. Ifyoir are unsure ifyaur license is on ftle, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: ' .fid . /a T�l '���,
-OR- Lot #.: — Block #: ` Subdivision:
What type of properly: ❑ Residential ❑ Commercial
Cost of job: $
Description of work: o, .
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
as Line = $65 a 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 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. 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 statementor misrepresentation of Fact in the application or on the pians on which tile permit or appro,
started within 180 days. Permit void If worlkstuns for 180 days. val was basedPermit void If not
Applicant's Naive (print): !-Q ignature:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be sched led for the next business day.
Inspection Hotline - (208) 372.2344
www.rexbu rg.org Permit Technician - (208) 372.2341