HomeMy WebLinkAboutAPPLICATION - 18-00720 - 2562 S 4000 W - County Gas for Generator`�µtYB(QI
CITY o F Building Safety Department
1E1MG BUILDING PERMIT FORM City of Rexburg
n. Updat,d2/2017 410 35 North 1St East
Americas hitmily Community
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Mechanical Work
For Office Use
Permit Number: 1 " 00-7 2-0
❑ Mechanical Fees Paid
1. Property Owner
Name: L.0G#avt obi tilo �a W1
Address: "n(� o� �Sc�U� In Lioc�o (NeSf City:uVG
Phone:State: _ Zip Code:?
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)
0 No, I am working with the homeowner
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building. fLQ `C-_ 1342�
I
Business: I unit b i, (.l 1
c /
State License #: �
r%p Exp.: l fr o7G, 1
Address: ��_��-}Vi �'t,J � f
City: _1 th D U `k State: Zip Code: t1 G f
Phone: _ �ii7�5 �a � C�r'o �1 s
Contact/Rep. Name: Email: SIF ua l y ,r 0l"
�d �--�
Phone: Email:
Mechanical Contractor Authorized Signature:
A copy ofyour state registration/license is requiredto be on file. If this is the first timeyou have done work in the City of Rexburg, ]lease provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by callinq (208) 372-7349
3. Project Description
Address:3 S & a - gbct V J
-OR-
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $� f
Description of work: � ✓0-E'C+ U Cts -fn OPtA ov-r;
4. Fees: Check all that apply:
❑ Furnace or A/C = $65
a Gas Line = $65
❑ Water Heater = $65
Lot #: _ Block #: — Subdivision:
❑ Fireplace/Solid Fuel Burning Unit:
o Built-in = $130
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 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. 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): T2cc
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