HomeMy WebLinkAboutFA APPLICATION - 18-00042 - 1175 W Main St - Valley Wide - Storage ShedC I TY OF
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BUILDING PERMIT FORM 4,Q
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d1012016
BUILDING APPLICATION
Fire Alarm
Building Safety Department
City of Rexburg
35 North 1st Cast
Rexburg, Idaho 83440
Permit Number:
Fire Alarm Fees Paid ❑
Name -.011 P:'4 i ,` f pCp -p /'a V_e
Address. � 7, . _ Ci
-j City.
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State: � Zi Code:
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Phone: 1- ) . Email: ° ,
� 3 5�'��5 -q Email:
:. Contnictor
Business: I f .l QL 414,rm e.rV,'r State License #:
Exp.: % 41,JQJ
Address: ")(72 14 �r'- ee L City: �- -
State: , . Zip Code: !2� V01
Phone: Email:
Contact/Rep. Name: P11one:i9-7C)q 7.,T 7Cn
Email: -"
Contractor Authorized Signature: L
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Date:
A copy ofyour state regiistrationflicense is required to be on file. if this is the first time you 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.
Address:,
Description of work: Flute Al C1_Y'Y,,
Fees for fire alarm systems are charge by cost:
o First $10,000 = 2% + $60. From $10,000 to $100,000 -1 % + $260. Above $100,000 =.5 Yoo +$1,160, i.e. Work costing
$15,000 will he charged $260 for the first $.10,000 and 1 % of the remaining $5,000 = $260 +$50 = $310 total fee
• There will also be a plan review fee totaling 10% of the above fee.
.APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHOR17ATION; Under penalty of perjury, I hereby certify that I have read this application and state that the information herein
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 of the City
to enter upon the above-mentioned property for inspections purposes. NOTE: The building afficial 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 if work stops for 180 days.
Applicant's Name CprintT � &Ni- Signature: R Date:
Inspections must he 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