Loading...
HomeMy WebLinkAboutAPPLICATION - 18-00086 - 525 S Center St - Taylor Chillero PE%a pq% p CITY OF RMURG — iNv Amerlm},eni[rrommunay Building Safety Department City of Rexburg 35 North 1Ft East Rohr..,. Td-h-OoA nn COMMERCIAL REMODEL/TENANT IMPROVEMENT APPLICATION CHECKLIST The following items should be completed before you submit your building permit application. *Reasonable accommodations will be made unon r•�oue t. Submit the Following Documents: ❑ 3 sets of building plans - stamped by a licensed professional. Include the following as applicable ❑ Foundation Plan, Floor Joist Layout, Floor Plan, Roof Layout Truss Details, Sectional Views, Front, Back, and Side Elevations, Mechanical Layout Stair Details, and any details required to illustrate special construction. ❑ Electrical panel layout and calculations included with building plans. ❑ Exterior Lighting Plan including photometric layout. ❑ Structural Calculations (if applicable) -stamped by a licensed Engineer ❑ Digital Plans (PDF Format- can be submitted by USE, CD, or Dropbox) ❑ **Copies of any Contractors' State License if not on file already. Complete the Following Forms ❑ Permit Policies Acknowledgment signed ❑ Building Permit Application signed by a registered General Contractor ❑ Mechanical Permit Application signed by a registered Mechanical Contractor ❑ Electrical Permit Application signed by a licensed Electrical Contractor ❑ Plumbing Permit Application signed by a licensed Plumbing Contractor ❑ Fire Alarm Permit Application (if applicable) signed by a registered professional ❑ Fire Sprinkler Permit Application (if applicable) signed by a registered professional ❑ Subcontractor list filled out ❑ Affidavit of Legal Interest signed by owner ❑ Notifications Distribution List ❑ Business Use Summary Completed Subdivisions: If you plan to build in a subdivision please check the Rexburg Development Code for any requirements such as property setbacks, architecture board approval, etc. This information is available at htt .//rexhurvgrg�Rges/de elonme r oae. In MIOn Hotline -[208)322.2344 ww tmburg.org Permit Technidan-(208)3]22341 Revised 10/2016 o psuUpp, CITY OH 6 REXBURG ti Amenm'sFmmily Commwiry PERMIT POLICIES ACKNOWLEDGMENT Building Safety Department City of Rexburg 35 North lot East Rexburg, Idaho 83440 The City of Rexburg Building Safety Department is determined to provide excellent customer service. In an effort to help you understand the City of Rexburg Permit Policies, listed below are several policies which you are required to know prior to proceeding with your project Any construction within the City of Rexburg which requires a permit shall not begin until an approved permit is obtained. If you do not have a Pink Building Permit signed by the Building Inspector, then you do not have an approved permit. o Building without the pink building permit signed by the Building Inspector will result in double fees to be assessed and the project to be red tagged. Ifyour project is red tagged, halting all construction, only a City m.nala Official may remove the red tag. Ifthe red tag is removed by anyone but a City Official, citations may be issued. No building may be occupied without receiving a signed Certificate of Occupancy. o If a building is occupied without receiving a signed Certificate of Occupancy, citations maybe issued and the occupants may be evicted. mihals Scheduling inspections is the responsibility of the applicantand their contractor. inspections need to be called into the hotline and not to the inspector. Inspections called in later than 8 AM will be scheduled for the following business day. o If an inspection is not done, the inspector may require any measures to be taken to allow him to correctly perform the inspection. (Example: If the electrical rough in inspection is not done and the sheetrock has been Imnma put up, the inspector may require the sheetrock to be removed in order to perform the electrical rough in inspection.) Construction on any project can begin Q [ when you have received a Pink Building Permit from the Building Department Occupancy of any structure can begin ONLY when you have received an official Certificate of Occupancy from the Building Department These documents must be signed by the appropriate authorities from the City of Rexburg. Any approvals can be verified by calling (208) 372-2341. ❑o Even ifyou hear from an inspector that'you're good to go', ultimately if you do not have a Building Permit or minalz Certificate of Occupancy, the above policies will be enforced. It is your responsibility to inform anyone on your project of the above policies. All sub -contractors will be held to this standard with no exceptions. o The above policies will be enforced to all, regardless if this information is passed onto them or not. mHals Applicant's Name (print): Andrew W01)0rd Signature: Date: 2/13/2018 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 to, he nest business Lay. Inspection Hotline -(208)372.2344 www.rexinut,cg Permt Technician -(208)372.2341 HAod 10/2016 yOF 0.E%a 4YC b CITY OF REXBURG BUILDING PERMIT FORM ZO1 — E� an ra,:ora Amenw's Family C Mhdm y BUILDING APPLICATION Commercial Remodel Building Safety Department City of Rexburg 3S North lot East Rexhnra. ldahn RZAAA For Office Use Permit Number: Application Fee: ❑ $100 1. Property Owner Name: Brigham Young University - Idaho Address: 525 South Center Street City: Rexbura State: ID Zip Code: 83460 Phone: 2084962664 Email: 'ohnqQnaul. du 2. Applicant Name: Bia-D Construction Coro Role: (Owner, Tenant, Contractor etc.) Address: 343 East 4th North Suite 112 City; Rexti rte_ S�D Zip Code: 83440 Phone; 208.709.9761 Email: andrew wolford@big-d com Contact/Rep. Name; Andrew Wolford 3. General Contractor Under Idaho Building Code, a registered contractor must do the work for a Commercial Building. Name: Bia-D Construction Coro Registration It: RCE -4751 Exp.: 12/28/2018 Address: 343 East 4th North Suite 112 City; Rexburg State: ID Zip Code: 83440 Phone: _ 208 709 9761 Email: _ andrew wolfordlrDbig-d Co Contact/Rep. Name: Andrew Wolford Phone: 208 709 9761 Email: andrew lkolfordnbig-d cam General Contractor Authorized Signature: Date: A copy ofyourstate registration/license is required to be Muffle. If this is the first timeyou have done work in the City of Rexburg, please provide a photo copy ofyour license. Byou are unsure i%your license is on file, please check with the Permit Technician by calling (206) 3722341. 4. Project Description Address: 525 South Center Street Description of Work: Replacing 3 chillers in different locations on the BYU Idaho campus Project Description: - • Total cost of project -materials and labor: $ 1,279.a49.00 • Check all that apply: ❑ Mechanical: Cost $236-7"0. 0 ❑ Electrical: Cost $337 Zoo DD 11 Plumbing: Cost $_ ElFire Alarm: Cost$ 13Fire Sprinkler: Cost$ Note: Any contractors involved will need to rill out their respective application. • Change of Occupancy? ® No ❑ Yes: New occupancy: Building Permit fees for commercial construction are charged based on square footage and the City's estimated valuation. The applicah'on fee applies toward the fee total. For details on how fees are calculated, contact the Building Department There will also be a plan review fee totaling 10% ofthe building perrakfee. "'—URE, CubTiFICATIVNI Ano AUTHORIZATION:Ondespenalty ofperlurgtherebyartfy that l have read HIS applkation connote thatow Information herein I. mrrectand I s.,,be, any InformaXon which may hereafter be given by mein hearings before the Planning and Zoning Commission or Is City Coundl for the City of Rexburg shall be truthful and correct 1agree m es"Ply with all Cltyregulatlems and State law relatingmthe subject matter of this application and hereby authorised representatives of m Litym enter upon [M1eabave-mentioned property forinspections purposes NOT& The building ORcial may retake a Palms an approval issued under the enormous of1a 21112 International Code in uses along false statement or misrepresentation affect in he application oron Ne plans on which the perm', or approval was based. P—n-id anot started Within 180 days. Permit void Hwork stops for 180 days. \) Applicant's Name (print): ADdf2W Wolford Signature: Date: 2/13/2018 Inspections mint be called In before a AM on the day the ins InspecXan Ho[Ilne- (208) 372.2344 section u r quested. lnspeotion requests called In after AM will be scheduled 1, Am neat business day www.m.m,.mg aA •`ja`a� C IT r 0 P Building Safety Department a 7�nvnTT'r��+ ' 1�L'aADVl\li BUILDING PERMIT FORM 21� City of Rexburg t,,, Janata 35 North let East ,loneco4z fa"sIn.'d'nam' Rexburg, Idaho 83440 BUILDING APPLICATION Commercial Mechanical For Office Use Permit Number. Mechanical Fees Paid El 1. Property Ovuner Name: _ Brigham Young University - Idaho Address: 525 South Center Street City: Rexburg State: ID Zip Code: 83480 Phone: 208,4962664 Email: iohnsona@byui.edu 2. Mechanical Contractor Under Idaho Building Code, a registered contractor must do the work far a Commercial Building. Business: Lewis Corporation State License a: HVC-C4440 Exp.: 5-31-19 Address: 15136 W Hunziker Rd City: Pocatello State: Idaho Zip Code: 83202 Phone: 208.238.1202 Email: kenyan@lcorp.com Contact/Rep. Name: Kenyan Lewis �e: 0 mail: kenyan@lcorp.eom Mechanical Contractor Authorized Signatur i Date: 2-13-18 Ampyofyourstateregistratian/licenseisrega �d to file.lfthis is thefrsttimeyou have done work in the City of Rexburg, please provide a photo copy afyour license. Ifyou are unsurei} frlicense isonffle please check with the Permit Technician by calling(200)3722341. 3. Project Description Address: 525 South Center Street Description of work: Replacing 3 chillers in different locations on RYLj-Jd@hct campus ❑ Project Cost: $ 936,750.00 • Feesfor commercial projects are charged by cost o First S10,000=2%.$60. From $10,000 to $100,000 = 1 % + $26a Above $100,000=.5%*$1,160. la Work costing $15,000 will be charged $260 for the first$10,000 and I %ofthe remaining $5,000= $260 a $50 =5310 • There will also be o plan review fee totaling 1096 ofthe abovefee. APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalryafperlury, I hereby rectify Mat I have read his applaud.. and slate that the iafmmanon herein Is correct and I swear Met any intrinsi on which may hereafter be given by me howarm,losfprnme Planning gad Zoning Commisalon ar the City Crucial for the City of Rexburg shallbetrutbfulandcorrect Iagme to simply with all Cityregulanons and State laws refund, to the subject matter ofm@application and hereby autboriaed representatives ofthe Ciry ro enterupon tM1eabove mentioned property Mrinspecnons Wrposes. NOTE: The building model may revoke a permit on appmwel Issued under Me pmvislans of the 2012 International Code in uses ofany false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based PenMt wild if not sorted within 180 dws. Permit void If work sense for IN days. L�_Applicant's Name (print): Kenyan Lewis Signator Date: 2.13.18 Inspecomw must be raped in here in 8 AM on me day Me insWomm is requested Inspection requests ended in after 8 An will be wind hied for Ne next business day. Inspection Hotline -(208) 372,2344 www.rexburgorg Permit Technician- (200) 372.2341 """"'a, CITY OF Building Safety Department •" REXBURG I BUILDING PERMIT FORM 220 City of Rexburg wa.�¢t¢,>ata 35 North 1st East Ace.:F.muyr ring, Rexburg, Idaho 83440 BUILDING APPLICATION Commercial Electrical For Office Use Permit Number, Electrical Fees Paid ❑ L Prnncrty Owner Name: Brigham Youno University - Idaho Address: 525 South Center SLmat City: RexburgState: ID Zip Code: 83460 Phone: 208.496.2664 Email: (ohnsona0bvui edli 2. Electrical Contractor Under Idaho Building Code, a registered contractor must do the work for le Commercial Building. Business: Mnutdain West ElOadc, Inc. State License g: ELbG3802 Exp,; 1113111/1 Address: 5116 Wast Highway26. gl City; aletklool state; ID Zip Code: 83221 Phone: (2081689.5463 Email: db0wnelemlawe5leOCCOM Contact/Rep. Name: Steven Thompson Phone: (208)684-5463 Email; shotnOsopC'ntlawastelebcON, Electrical Contractor Authorized Signature: no* e" ----'—t Date: ?/13118 A copy ofyour state regiscrution/licence it required to be unfile. If this is thefirst tlmeyou have done work in the Cigof ... y, pleuroprovldfr a photo copy ofyour license. Ifyou are unsure ifyourlicense is on file, please check with the Permit Techmcino by calling (200) 375-2341. 3. Project Desn iptlon Address: 525 South Center Street Description of work: Re to acioti 3 chillers in different locations on BYU-Idaho campus 0 Project Cas, $ 37,200 • Feeaforcommercialpro)ects ore charged by cost. o First$10,000=2%+560.Front $10,000 to$100,000=1%+$260. Above 5100,000=.5%+51,160. i.e. work cashing $15,000 will be charged $260for the first$10,000 and 1% of the remaining $5,000 = S260+S50 - S310 and fee • There will also be a plan reeiewfee totaling 10% of the abovefee APPLICANTS SIGNATURE. CERTIFICATION AND AUTHORIZATION: Undo, pewl,id,wary.l hereby rnnf(y that I have mad this npplicatinn and pate thount, inam2titm hurtin is and I swenchat onylntmnr inhe which may hereafter be given by mein M1earingsbafom the Planning and Zoning C—alsolnn or City Cwn[U ter the City of nexhurg shall W truthful and attract Iause 1. a.c,)Iy with all City regulations and State lata relating tot lie subject ma ter oI not sInWaann.ma huruby nalchnad calices[ sof the Ciry to enter upon lite above.merun ned property fm mspe¢ionr purpoms. NOTE: The and ingollicial may mvukea permit on apon-il trued uMerthu novitiates oft he2012 Invocational Cade In cares of any false semen[ or mbmleali ntadonaf fact in the imnimdanar on Ne plans on which the force car approval ones based, looms tvuid If nm mored within Igo days Permit void if work sops for too days. Applicant's Name (print): Bart cancer Signature: &A, }_ Date: 211312018 Incp205th¢ trilled in before a AM omlmduy Ne Inspetlf¢n rs requesmd Inspection r¢quests rallrM in anerg AM will be aM1etlulai fur tb¢n xr baso as Inapa[tlon llotfinsabte- f2081372.2349 mww.reabur8org P¢rmia Techpinaw (iae)3723Ix 2342 '°tea"° c I TY OF Building Safety Department a a ° RE—) BUILDING PERMIT FORM Z30 City of Rexburg IN, 35 North tat East Amerlwt Fmmp community Rexburg, Idaho 83440 BUILDING APPLICATION Commercial Plumbing For Office Use Permit Number: Plumbing Fees Paid ❑ 1. Property Owner Name: Address: City: State: Zip Code: Phone: Email: 2. Plumbing Contractor Under Idaho Building Code, a registered contractor must do the work for a Commercial Bui Business: State License #: Address: City: State: ip Co Phone: Email: Contact/Rep. Name: Phone: Email: Plumbing Contractor Authorized Signature: Date: - I copy ofyourstate registration/license is required to be onfile. lfthis i efrst tim u ework in the City of Rexburg, pleaseprovide a photo copy ofyourlicense. Ifyou are unsure ifyour license is heck wit a Permit Technician by calling(208)372-2341. 3. Project Description Address: Description of work: ❑ Project Cost: $ • Feerforc tial projec cha by cost: o Firs 0,000=2% 60. Penn $10,000 DO$100,000=1%t$260. Above $100,000=.5%+$1,160. i.e. Work costing 150 ill be charged$260for theFrst$10,000 and 1% ofthe remaining $5,000=$260+$50=4410_ Therem (robe Ian review fee totaling l0%of the above fee. ►vi APPPCANT351GNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty Inferior, l hereby certify that l have read this application and state that rhe inrormatl°n herein is correct and I swear'hat any information which may hereafter, be given by me in been., before the Planning and Zoning Commission or the City Council for the City of Rexburg shall be tmMful and correct. I agree In comply woh all City regulations and State laws relating to the subject matter ofthis appliksumn and hereby authorised representatives of the City to enter upon the above-mentioned property for Inspections purpose, NOTE: The building official may revoke a permit on approval Issued under the prevision ofthe 2012 afternrmem Cede In rases of an, firs, statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permitvoid if not started within 180 days. Permit void ifwork stop for 180 days. Applicant's Name (print): Date: Inspections must be talked In before SAM on the day the Inspection Is requested Inspection requests called in after 8 AM will be scheduled for the east business day. Inspection Hotline -(208)372.2344 www.reiverg.org Permit Terbium—_n ic17s oval o F�xatea CITY OF Building Safety Department Q )BURG I BUILDING PERMIT FORM 401 City of Rexburg ti 35 North 1st East Amenmt Family Community Rexburg Idaho 83440 Office Use L Property Owner Contractor Name: BUILDING APPLICATION Fire Alarm Contractor Authorized Signature: A copy ofyour state registration/license is required to be a photo copy ofyour license. Ifyou are unsure ifyour lice. 3. Project Description Address: Description of work: ❑ Fire Alarm System 40$ State License It: City: Email: _ Phone: Fire Alarm Fees Paid ❑ State: Zip Date: le work in the City of Rexburg, please provide Technician by calling (208) 372-2341. e Fees r rmsystems echargebycost: Firs 0,000=2%+$60. Fro. $10,000 to$100,000=1%+$260. Above $100,000=.5%+$1,160. i.e. Work costing `e(Thert $ 150 ill be charged$260for theffrst$10,000 and 1% afthe remaining $5,000=$260+$50=5310 tnmifaa also be a plan review fee totaling 10%of the above fee. .APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under pe ma and 1 swear that any information which may hereafter be given by me be trutM1ful and correct 1 agree to comply with all City regulations and State la W enter upon the above-mentioned property for Inspectlan, purposes. NOTE: International Code Incases of any false statement or misrepresentative of fact started within 18o days Permit void if work amps Por 188 days. Applicant's Name (print): '.wdfy that I haw read this application and state that One information herein .hung and Zoning Commission or Ne City Council for the O n of Rexburg shall natter oftM16 application and hereby authorized representatives atom City revoke a permiton approval issued under the provisions ofthe 2812 e plans on which the permit or approval was based Permltvoidifmt Signature: Date: Inspecdons must be called in before SAM on the day the Inspection is requested. Inspection requests called In after g AM will be scbedulsd for the nen business day. Inspection Hotline- (288) 372 2344 www.rexburRorg Permit T,,b,icieu-rural 172 2141 +�•e.M Building Safety Department w 0 CITY OF EX BUILDING PERMIT FORM 4,02 City of Rexburg ose °°'°f°" 35 North 1•^ East A—Has Fiily Commonly Rexburg, Idaho 63440 BUILDING APPLICATION Fire Sprinkler For Office Use Permit Number: Fire Sprinkler Fees Paid ❑ I. Property Owner Name: Address: City: State: Zip Code: Phone: Email: 2. Contractor Business: State License K: Address: City: Stat Zip e: Phone: Email: Contact/Rep. Name: Phone: Email: _ Contractor Authorized Signature: Xv I Date: A copy ofyour state registration/license is required to be onfil's efrsttl ou edone work in the City of Rexburg, please provide a photo copy ofyour license. Ifyou are unsure ifyour Uteri orifi le chec i the Permit Technician by calling(208)372-2341. 3. Project Description Address: Description of work: Number of Heads: ❑ Fire Sprinkler Cast: $ fro m systems are charge by cost: o first 000=296+$60. From $10,000 to$100,000= 196+$260. Above $100,000=.546+$1,160. i.e. Work costing 15,000 will he charged $260 for the ffrst$10,000 and 195 of the remaining $5,000 -$260+$50 = $310 total fee ill also be a plan review fee totaling 10% ofthe above fee. APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjurg 1 hereby certify that l have read this application and state that the Information herein correct ven and I swear that any information which may hereafter be giby mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg shall betruthPol and co..co I agree to comply war all City regulations and State laws relating to the subject matter of this application and hereby authourd 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 efthe 2012 International Code In cases of any false statement or misrepresentation off xt in the application or on the plans on which the permit or approval was based, Permit void if not started within 180 days. Permit wild Ifwork shops for 180 days. Applicant's Name (print): Signature: Inspections most 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.mg permit Technklan- (20813]2.2341 OF pexavgC CITY O F b REXBURG 0i,— 6YI1KK1]LLIYY t7[111111toa W Excavation & Earthwork: N/A Building Building Safety Department City of Rexburg 35 North lxt East Rexburg, Idaho 83440 Concrete: Richardson Concrete Inc. Masonry: N/A Roofing: Thomas D Robison Roofing Inc Insulation: N/A Drywall: N/A Painting: N/A Floor Coverings: N/A Plumbing: N/A Electrical: Mountain West Electric Inc Special Construction (Manufacturer or Supplier) Roof Trusses: Floor/Ceiling Joists: _ Siding/Exterior Trim: Other: Inspection Hotline -(208)3)2.2344 µrvnv.rexburgorg Permit Teehnician-(208)3]2.2341 Revised 10/2016 � y clrr OF a ° REXBURG ,�tmmtyan,nmm„y Affidavit of Legal Interest Building Safety Department City of Rexburg 35 North Sn East Rexburg, Idaho 83440 State of Idaho County of Madison I, !9 )L42N NIEL'5Ut r) 0;2 S rENT>=P Name Address Being first duly swam upon oath, depose and say: (if Applicant is also Owner of Record, skip to B) P&+Aa State A. That I am the record owner of the property described on the attached, and 1 grant my permission to: RILL©N NIELEN �i'2_G1�i.Gt:NTBKI gs,=%WKc,1 VG400 Q334.60 Name Address to submit the accompanying application pertaining to that property. B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any claim or liability resulting from any dispute as to the statements contained herein or as to the ownership of the property which is the subject of the application. Dated this I + ` Lday of BY4%" 20—�� Slgnatur Subscribed and sworn to before me the day and year first above written. (y ^ r Notary Public of o.L�I Residingat: TJi =l�p„yly My commission expires: /] __'I / W,23 I.tlxran I ImUme - (208) 372,2344 www.revbuB^A Perm It TemmicIea-208 3723341 1 ] Revisetl So, 7O16 # c r u OF REXBURG �. amer�mt rnm(ty co�nwn�y DISTRIBUTION LIST Building Safety Department City of Rexburg 35 North 151 East Rexburg, Idaho 83440 Please provide the names and emails of anyone who should he getting automated updatesfor this project. Review Notes Name: Andrew Wolford Name: Eric Waters Name: Tyler Ames Name: Email: Name: Inspection Tickets Name: Andrew Wolford Name: Eric Waters Name: Tyler Ames Name: Name: Email: andrew wolford(ftiii-d com Email: eric.watersc@bia-d.com Email: eno.waters0big-d com Email: tyler.am9s(@biq-d.com Email: tvler.amesca)bio-d.com Email: Email: Email: andrewwolford(@big-dcom Email: eric.watersc@bia-d.com Email: tyler.am9s(@biq-d.com mxpectlon xoom¢-(zae)372.23aa mww.rexburg.urg Permit Tecenidan-(208)372.2341 MW 10/2016 a CITY OF Building Safety Department ° R URG City of Rexburg cV 35 North lat East nn Wr Tommy con,nnniy Rexburg, Idaho 83440 BUSINESS USE SUMMARY The following questions will help speed the review process along. Please take the time to answer all of them. Is this business occupying an existing building? Will the business be doing any structural/or remodeling changes to the building? Any changes to the electrical? Any changes to the plumbing? Any changes to the mechanical system? Is the business type changing? o Yes, it will change to Is this business changing ownership? Is the business registered with the City of Rexburg? ® Yes, License #: "If No, please apply for a business license with the Customer Service Dept Will the business have food preparations? Will there be any cooking of foods? Will there be any deep fat frying? Will you have food disposal on site? Will there be sumps or floor drains in the facility? Will the business have any chemicals on site? 208.709.9761 2/13/2018 Applicants Signature Phone Date ® Yes o No ❑ Yes a No ®Yes ❑No ❑ Yes ® No ® Yes o No ® No o Yes in No _❑No o Yes ®No []Yes ® No o Yes ® No 13 Yes ®No o Yes ® No ®Yes 1:1 No I certify that the information that l have provided above is to the best of my knowledge accurate and true. haaPeetion Hodine-(208)3]22344 w '.abu'.or6 Permit Technician -(20813]22341 Retired March, 2016