HomeMy WebLinkAboutAPPLICATION - 19-00003 - 885 N 12th W - Shop Heater - Gas Lineo� t�uxarikG
rd CITY o F Building Safety Department
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R1+ 3�.�RG BUILDING PERMIT FORM 112 City of Rexburg
Updated 2/2017
'', •' 35 North 1St East
America's Family Community
Ph20
Rexburg, Idaho 83440
BUILDING APPLICATION
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For Office Use
Permit Number:
❑ Mechanical Fee Paid
1. PropertyOwn r
Name: ��,� �iylrylEL
Address: �r �% 724 City: State: f/Zip Code: �3 `7
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Phone: _Z D 3/; 7- 6&,5'e 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 3 of this application and complete the Homeowner's Exemption page as well)
(D-X'o, I am working with the homeowner
2. Mechanical Con ractor t
Business: 1 4 �� 11 S Stat License #: ��`�- /6a Ex p>Z%
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Address: 227 ZS'o A. City: - State: 1,� Zip Code:9_5,41V47
Phone: ti - �' p Email: .aQ°uZZ/I
Contact/Rep. Name: 2L 1.h sfl/ Phone:
Mechanical Contractor Authorized Signature: Date: '
A copy of your state registration/license is required to be on file. If this is the st 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.
3. Project Description
Address: _ r, V ,0? rtr AO
Description of work: Q�
❑ SFR Addition Construction: sq. t.
• Fees for additions are charged by square footage: Up to 1,500 sq. ft. = $130 + $65 for each additional 1,000 sq, ft. or portion
thereof.
0 Up to 1,500 sq. ft. = $130. Up to 2,500 sq. ft. = $195. Up to 3,500 sq. ft. = $260. Up to 4,500 sq. ft. = $325, etc. (i.e. a
home with 3,675 sq. ft. will be charged $325)
❑ Number of Fireplaces:
• Note that fireplaces are not included in square footage costs and will be charged $65 per inspection.
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 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.
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Applicant's Name (print): SignatDate:/ V
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Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests4afteill be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org g g Permit Technician - (208) 372.2341