HomeMy WebLinkAboutAPPLICATION - 17-00574 - 305 E 1st N - Electrical OnlyC I TY OF
REXBURG
Amedcas Family, community
Building Safety Department
BUILDING PERMIT FORM 420 City of Rexburg
°ra°W213017 35 North 15t East
BUILDING APPLICATION
Miscellaneous Electrical Work
Rexburg, Idaho 83440
For Office Use
Permit Number: 14 K Electrical Fees Paid
1. Property Owner.
Name: �fl tP.e (X 14—
Address: 305 EGsF �- X4 City: ) Start �� ZipcodPYY�
Phone: 0OR -- 403-q13,2-- Email 6x V4100- oi�
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.
6 r �
I unc�� eG/i G nG . State License #: C- (�� Exp
.:Business:
Address: q-7 Milt I lce 9.d, City: RzkL eg State: I D Zip Code: 93`ic/6
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Phone: (Z0 01i`� o R - 5 ' EI -t Email:
Email:
Contact/Rep. Name: Phone:/'
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Electrical Contractor Authorized Signature: Gam- Date:—
A copy ofyour state registration/license is required be o file. If this is the first time you have done work in the City of Rexburg, please provide
a photocopy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description y
V ��/�
Address: /- . OR- Lot #: _ Block #: _ Subdivision:
What type of PropertyA.Residential ❑ Commercial
Cost of job:$ q] L
Description of work: /"� W 6I Icc PIS u Se
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-inspectfees will be
tower or drive motor = $
enforced if inspection requests exceed fee totals.
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, Ihereby 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 he 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 Cade In cases ofany false statement or misrepresentation of fact In the application or on the plans on which the permit or approval was based. Permitvotdifnot
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): 5�` CL &,-Signature: Date: -/—// �/
Inspections must be called in before 8 AM on the day the Inspection is requested. Inspection requests called in after 8 AM will he scheduled for the neat business day.
Inspection Hotline- (208) 372.2344 www.rexhurg.org Permit Technician- (2013) 372.2341