HomeMy WebLinkAboutAPPLICATION - 17-00769 - 2581 S 1400 W - Gas LineCITY OF
REXBURG
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Ameriml; Family Community
BUILDING PERMIT FORM 410
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BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ��-�a%G�i XMechanical Fees Paid
1. Pro er�0 r
Name: ty/y/iLe /A) I/AJO-1
Address: RS -015-.m llloyt.4er- City: State: SO Zip Code: tF3yy0
Phone: g/6 - 28`!-06/5 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)
Erfgo, 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: 4ex6h P! r lie. �K State License #: Exp.:
Address: 766N rllowsro.e City:�av1State: J'V Zip Code: ewo
Phone:2 0�- 3 G - e77 03 G ^X77 9 Email:
Contact/Rep. Name: ".dp,ePhone: 7W -510-f`,70- Email:
Mechanical Contractor Authorized Signature: � Date:
A copy ofyour state registration/license is required to be n file. If this is the fir t 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: -OR- Lot #: Block #: Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
4. Fees: Check all that apply:
V❑ urnace or A/C = $65 ❑ Fireplace/Solid Fuel Burning Unit:
0 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, I 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 mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct. 1 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. Permit void Hoot
started within 180 days. Permit void ifwoork stops for 180 days.
Applicant's Name (print):N,/��k�e�lu - Signature: Date: 13DFe-?*1
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 - (2 08) 372.2341