HomeMy WebLinkAboutAPPLICATION ELECTRICAL - 17-00695 - 66 E Main St - Progrexion - RemodelCITY OF
REY BUILDINGPERMITFORM 42�
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Amencas Family Community
BUILDING APPLICATION
Miscellaneous Electrical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number. 14-6b(095 XElectrical Fees Paid
1. Property Owner
Name: INIXXIA SEE?=
Address: ioat A.A7 tr QMQ! oelyE City: 414eR IiEIt.LSS S State: V7 Zip Code: 8932)
Phone:(31 M N4N- ! 21st Email: Stt I ZCT'e A I•>L Aim 1'&M&
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 Homeowners Exemption)
0 No, I am working with the homeowner
2. Electrical Contractor
Under Idaho tI
BuildingI.P. jCode, La registered contractor must do the work for a Commercial Building. �1
Business: ' 4 E C�'M i t- State License #: V j35 �' Exp.: / 1 3) / I t
Address: o P.O. Rog City: tz tP G State: F D IZip Code: 193 437
Phone: J10% -3'10--7r7!7 Email S V In � S*WV 6 S e d i.6 • ��
Contact /Rep. Name: S Phone: ^un-J90-7T77Ema l: dSuT� ✓6er.ds ,51
Electrical Contractor Authorized Signature: h/,�,�rrJ Daterl/d 1/17
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. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: C.01, C. -;r -OR- Lot #: _ Block #: _ Subdivision:
What type of Pro erty: ❑ Residential ®-Commercial
Cost of job: $Qo•LbI�
Description of work: t A< yi [ w av {' LtTs C'
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 2SHP
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 ofperjury, l hereby certify that l have read this application and state that the information herein
is correct and 1 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 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 in cases of any false statement or misrepresentation of fact in the application or on the plans on which theaermit orapproval was based. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days. /II / l I
Applicant's Name (print): ]]YZ1►G 5U7{Wn Signature: LL_ A� 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
,LOP