HomeMy WebLinkAboutAPPLICATION - 19-00099 - 77 S 1st E - Gas FireplaceCITY O F
REXBURG
America's Family Community
BUILDING PERMIT FORM 210
Updated 10/2016
BUILDING APPLICATION
Commercial Mechanical
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
For Office Use
Permit Number: 19 ,L -On 59 Mechanical Fees Paid ❑
1. Property Owner
Name: ►` His/ H ZO WS
Address: `77 S / -T City: 7"7CX 1A6 I c
ty State: -�-� Zip Code: �' 7A1
Phone: Email:
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: State License #: 00" -
�� 5Ex p.:.;,.W 2az2
Address: 3 ?.q 51 /09 tJ City:=D,t-/0 -194cs' State: sp Zip Code:
Phone: Zoq- 313 -yy77 Email:
Contact/Rep. Name: :9h(1,, nl Phone: Zo8 - 3 -'lY 7 Email: cm�rwt / 700. OO, C= Al
Mechanical Contractor Authorized Signature: C Date: ,-;,/z- g a
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 photo copy of your license. If you are unsure if your license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address:
Description of work: :7&A/� AS
❑ Project Cost: $ 4/4! !/P 2`
• Fees for commercial projects are charged by cost:
o First $10,000 = 2% + $60. From $10,000 to $100,000 = 1% + $260. Above $100,000 = .5% +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first $10,000 and 1 % of the remaining $5,000 = $260 + $50 = $310 total fee
• There will also be a plan review fee totaling 10% of the above fee.
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):
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