HomeMy WebLinkAboutAPPLICATION ELECTRICAL - 17-00239 - 295 Ella Ln - Kenneth Square Bldg 7 - MFR�extsuk
CITY OF
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V REXI3URG
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BUILDING PERMIT FORM 42
Updated 2/2017
BUILDING APPLICATION
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fA- f�%nn � Miscellaneous Electrical Work
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Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Electrical Fees Paid
1. PropertOwner
Name: P -o
Address:r`-72 City: State: _� Zip Code: Xf�li
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Phone: 9/20, 1>rdf' ��l' % 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 section 4 of this application and complete the Homeowner's Exemption page as well)
C7,< I am working with the homeowner
2. Electrical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: State License #: 666- -0-3F12-7 Exp.:
Address: L City: /'iZGs�s� State: -fw( Zip Code:
Phone: - -7!T9`-q4971_ / Email: fi
Contact/Rep. Name: K1m_11C1r^ P/ _ Phone: Emal : _41a,0-ne
Electrical Contractor Authorized Signature Date:
A copy ofyour state registration/license is required to blon file. If this is the first tirne you have done work in the City of Rexbt rg, p ase 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 17 -,= ZfKZ_
Address: A 7 _ -OR- Lot #: _ Block #: _ Subdivision: 4 7- -an 7-1fl
What type of Property:
ID Residential [&Commercial e, 1 , J7 �/ n
Costofjob: $_J/J, W(� ,Q.�G%1 ,e�G/ 7 ! `7Zia%
Description of work:.i!�
4Fees: 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 25HP
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.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, 1 hereby certify that I 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. 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 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
started within 180 days. Permit void
�fifwork stops for 180 days. s� '
Applicant's Name (print):1 ��� �G�i� SignatDate: �l
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