HomeMy WebLinkAboutAPPLICAITON - 17-00636 - 138 W 4th S - Acadia Apartments - Electrical OnlyCITY OF
REXBURG
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Amends Family Community
BUILDING PERMIT FORM 420
undated 2/2017
BUILDING APPLICATION
Miscellaneous Electrical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: �i OU63� �M Electrical Fees Paid
1. Property Owner
Name: Property,
�I_ R1/`xpINGS
Address: �iptl 3 ]PIrzy—N-z .D2 City:�9�+.t7RtE State:
Phone:
�3 �
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, 1 am working with the homeowner
2. Electrical Contractor
Under Idaho
��kBuilding Code, a registered contractor must do the worfor a Commercial Building.
/
Business: _ (yfi(F� LKC j 2 1 C LLC_ State License #: 07-t10$3 Exp.: 1131hr
Address:-S`d� (Z6f6t1`J 11/,E, City: 1 0-7fD FVFZts State: W Zip Code: 9
Phone: 70g :�; tl U Email: x r
Contact/Rep. Name: JEr}N-IV(CC(t!%i_ Phonoma- 90- fol Email: oRgNrif_r=t�cT2tC.,KNic.�vJC,nr.Frt
Electrical Contractor Authorized Signature' _ Date:
A copy ofyour state registration/license is requir o be on file. If this is the first time you have done work in the City of Rexburg, please provide
a photocopy ofyaur license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Descri ti0c
Address: 13 4 LIT4 &6 , r -I -I -OR- Lot #: Block #: Subdivision:
What type of Pr perry: esidential +fLommercial
Cost of job: $
Description of work: FI1L EtRNlyu c,h2wq,
4. Fees: Check all that apply:
❑ Central Heating/Cooling Systems = $65 ❑ Pumps - Water, Irrigation, Sewage (per motor)
Cl 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 20oHP
$ ❑ Spas, Hot Tubs, and Swimming Pools = $65
Y' 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.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that l have read this application and state thatthe 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 I agree to comply with all City regulations and State laws relating to the subject matter ofthis application and hereby authorized representatives ofthe
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 incases 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 180 days.
Applicant's Name (print):JEA�N-MICf4EL V' Signature: Date:��i Ig
KN IG KER(3 o GKN
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
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