HomeMy WebLinkAboutAPPLICATION - 18-00399 - 2026 S Fork Cir - FurnaceC I TY OF
REXBURG
America's Family Community
BUILDING PERMIT FORM 41 O
[Inflated 2/2017
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 15t East
Rexburg, Idaho 83440
For Glee Use
Permit Number: i 006 l Pf Mechanical Fees Paid
1. Property Own € m
Name: -
Address } -
City: 1� State: � -Zip Code:�`f`I
Phone: _ ��' I'17 -% Emaj . �2tao /ie r {
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)
❑ No, I am working with the homeowner
2. lyiechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building. 7
Business: )h State License #: Exp.: G
Address: City: t State: I r�^ Z'p Code:
Phone: Email! /
Contact/Rep. Name: JA ' _ Phone: Email: ��``
Mechanical Contractor Authorized Signature:
Date -
Mechanical
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
o photocopy of your license. llyou are unsure if yFour license is on file, please check with the Permit Technician ky calling (208) 372-234.1.
3. Project Description
Address -262&.1 +1 )�Ai O; Jde , -CIR. Lot #: _ Block #: _ Subdivision:
What type of Property: 0 -residential ❑ Commercial
Cost of job: $
Description ofwork:"`J Nr I
4. Fees- Check all that apply:
CFurnace or A/C = $65 [3Fireplace/Solid Fuel Burning Unit:
R ---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.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I 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 mein 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 taws relating to the subject matter ofthis 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 if work stop or 180 days.
�y
Applicant's Name [print): !,' L Signature:.. Date:9W,�_
Inspections must be called in before SAM 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