HomeMy WebLinkAboutAPPLICATION - 17-00650 -742 Nina Dr - Mechanical OnlyCITY OF
REXBIMG BUILDING PERMIT FORM 410
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Amerlm's Family Community
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use I h b ��
Permit Number: V ❑ Mechanical Fees Paid
1. Property Ownertn
Name: ( VT' 4�j4r4
Address: 76,2 De City: A ., ✓ s State: �W Zip Code: V y4'd
Phone: �f- Sl,Zfg Email:'M nf�• el..,
Under Idaho Building Code, a homeowner is allowed to do work on their own tome.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
U(No, l am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: ✓ Z State License #: fi1/L G - SZoy Exp.: 9-,2, n
Address: L j'} S p 5/roe U ij r City:< itl State:. -V— Zip Code: '9.3Y510
Phone: •toil, /Email:i— ,9
rcnt
Contact/Rep. Name: r1 n{m�yi��-✓o
rc =ate, •dam
Mechanical Contractor Authorized Signatur-: oc_ Date:2---,�
A copy ofyour state registration/license is required to be on file. If this is the first time you have done work in the City of Rexburg, please provide
a photocopy ofyour license. If you are unsure if your license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: be,. -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: AResidential ❑ Commercial
Cost of job: $ 7 H Sb r`
Description of work: 0 ,< o ec
4. Fees: Check all that apply:
A Furnace orA/C = $65 -e ❑ Fireplace/Solid Fuel Burning Unit:
❑ Gas Line = $65 o Built-in = $130
❑ Water Heater = $65 o Free-standing = $65
❑ Miscellaneous/Requested Inspection= $65
Inspection fees can be bundled upon request. Re -inspect fees will be 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 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 of any false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print):`�ey, J/Vh _ cSignature: a �� - Date: /o ti2S�As7y
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 - (2 08) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341