HomeMy WebLinkAboutAPPLICATION ELECTRICAL - 18-00662 - 77 S 1st E - Kitchen remodelCITY O F
REXBURG
C1461 -
America's Family Communify
BUILDING PERMIT FORM [�W
—_ Updawd 2/2017
BUILDING APPLICATION
Miscellaneous Electrical Work
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
Permit Number:
❑ Electrical Fees Paid
L Property O-;vner
Name: � fi n T l" o w _
p
� o T7
Address: 7 7 S City:
State: _Zip Code:
Phare:
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)
❑ No, I am working with the homeowner
2. Electrical Contractor
Under Idaho Building Code, a registered contractor must do the work far a Commercial Building.
/ .#.� iS
Business: �i I J ��L �e = �/ �
State License #: � 3 -j-1'-'—Exp. : 3a 8
Address: 4i �S City: —,?2Xh
a t _ State:. � Zip Code:
Phone:,a,Qg3 5(P ---3 % %D
Email:
Contact/Rep. Name: hone:
Email"
Electrical, Contractor Authorized Signatur
Dater
A copy ofyour state registrationficense is requ d to be on file. 1f th'
e first tune you have done work in the City of Rexburg, please provide
a photo copy ofyour license, tfyou are unsure ifyour License is on fa ,
please check with the Permit Technician by calling (208) 372-2341.
3, Project Description
Address- -OR- Lot #: Block #: Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost Of job: $
Description of work:
4. Fees: 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
Ilr New Circuits = $(65 + ($10 x # of branch circuits))
o $130 - over 200HP
$ / D Sb &V
❑ 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, 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. 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 if work stops for 180 days.
M
Applicant's Name (print): yroy Lel-,54y d t, Signat�. , Date: OWY,
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