HomeMy WebLinkAboutAPPLICATION - 18-00483 - 117 Madison Ave - SFR Remodel HVAC OnlyC I TY OF
REXI3URG
Americas Family Community
BUILDING PERMIT FORM 410
Updated 2/2017
BUILDING APPLICATION
Miscellaneous Mechanical Work
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office ,, e
Permit Number: CC e� `� ❑ Mechanical Fees Paid
L. Property wirer
Name: 1306 ( U 44.&A
Address: I AA It>cn J Av C i 3astmen4[City: _ tCr x6WA State: L6 Zip Code: A11440
Phone: o? d 9` -71(o ' D O % 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 ;;,wn.. t . f of this application and complete the Homeowner's Exemption page as well)
$j No, I am working with the homeowner
?. �It .l i'. is i, •, 11 t� _i 'ri, :,.
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: A�fuy\'�e..:vx 4ltiLT A4tykweiic✓( State License#: RTAC A C -1(o37 Exp.:
Address: V Sa00 S City:L-exb f!r State: �tll> Zip Code: 83440
Phone: a.o8 ' 3s-G� ORI0 Email: S6tg% 0.7 MW AA.t?rrvT. Cbrn
Contact/Rep. Name: S kav%t_ ` l \( Phone: 04OLW %420. Email:
Mechanical Contractor Authorized Signature: 's h" Date: 8%.30 - I lb
A copy of your 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
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: 117 M4'son Qyt C aastm e„T) -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: [/Residential ❑ Commercial
Cost of job: $
Description of work: t,M00(f(rct�AS6rn4*vT VA(,
4. Fees: Check all that apply:
E/ Furnace or A/C= $65 ❑ Fireplace/Solid Fuel Burning Unit:
❑ 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 of perjury, I hereby certify that 1 have read this application and state that the information herein
is 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 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 stops for 180 days.
Applicant's Name (print): Z�+ctvt C L l � Signature: -- Date:
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