HomeMy WebLinkAboutAPPLICATION - 17-00656 - 117 Madison Ave - SFR Mechanical Only0
CITY OF
REXBURG
OW
Americas Family Community
Building Safety Department
BUILDING PERMIT FORM410 City of Rexburg
n,dated'o/'o" 35 North 1st East
BUILDING APPLICATION
Miscellaneous Mechanical Work
Rexburg, Idaho 83440
For Office Use (�
Permit Number: 0 r 0 6 Y ❑ Mechanical Fees Paid
1. Property Owner
Name: OR 1 //iii
Address: -//, 7 Y51 wol DW A _ City: 1;eKZ?Gl1i^ State: --Lip 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 #4 and complete the Homeowner's Exemption)
No, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a register d contt racctor must do the work for a Commercial Building.
Business: State License #: vC ' ' Gip.:
Address: ,`TCity: GZ11Z4 State: Zi Code:
Phone: Email 02 y 0C/t-h7-_� �1i9iY'".I�iG �-Gn
Contact/Rep. Name: Phone: Email:
Mechanical Contractor Authorized Signature: Date:
A copy ofyour state registration/license is required to be on file. If this is t e first timeyou have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file; please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property:: Residential El Commercial
Cost of job:$ / p
Description work:
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 ❑ 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.
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, l hereby 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 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 Codein 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 workstops for180days. / Applicants Name (print):' �lf/ /GK-- Signature: Date:acll7
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after a AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341