HomeMy WebLinkAboutAPPLICATION - 17-00699 - 1733 W 4300 S - Tankless Install>•\
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CITY OF
J�LaG
BUILDING PERMIT FORM 410
OW
uvd.ud 10/2016
Amerim's Family Community
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Mechanical Fees Paid
1. Property Owner ' 1
Name: ib%nn 3 {iYnl1 f1uSMS
Address:-Pn LA) HS City: qfthwaState:TO Zip Code:
Phone: w)%-:og-QQS1 Email:
Under Idaho -Bu , ildhng Code, a homeowner is allowed to do work on their n home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
o, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: 1 tate License #:—}��i�Exp.: _� R�
Address: City: State: Zip Code:
Phone: at
Contact/Rep. Name: fa Phone: - - mail:
Mechanical Contractor Authorized Signature: Date:
A copy ofyourstate registration/license is required to be on file. If this is the 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 Descri tion
Address: 1y !n� y -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: 9`1esidential ❑ Commercial
Cost of job: $R,aAri.
Description of work:, U2B UDA(T 1ft%lI
4. Fees: Check all that apply:
❑ Furnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
13 Gas Line = $65 o Built-in= $130
XWater 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, 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 Read urg
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 statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based Permit void if not
�\
startedwithin180days Permit said iffamrrkstops for 180days.
Applicant's Name (print): 21 ,)y w(6m I. \ � 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 be scheduled for the next business day.
Inspection Hotline- (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341