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'° REXBURG BUILDING PERMIT FORM 3 2
0, Updated 3/2019
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I Ixew Construction
For Office Use
Permit Number: 1!1_001x,
I. ProperW Owner
Name: LAI, /ra.elts s
Address:
City.
Phone: �o
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Email:
2. Electrical Contractor
❑ Addition
State
Building Safety Department
01
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
Electrical Fee Paid ❑
Zip Code:
Under Idaho Building Code, a registered contractor must do the work for a Multi family Residence.
Business: t'L,e,,-
State License #: _ ()� qS- 7 `l —Exp.:
Address: /U .
r City. State: 1 D Zi C
Phone: _ '�-0�3 --7/b �13J � v p ode: �? 31/1/;1.
Email: C,'irE.y, ��5c, cert-�
Contact/Rep. Name: Phone:
Email:
Electrical Contractor Authorized Signature: ?'It /1 ( ?
A copy ofyour state registration/license is required to be on fie. /f this is the first time you have done work in the City of Rexate: 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: 733V tV a 1'13ks� -OR- Lot #: _ Block #: _ Subdivision:
Description ofwork: _ia4rt X09&,,,_ M Z, Q_
❑ New MFR Construction. # of Buildings: # of Units:
Fees are charged by number of buildings and number of units.
o (130 x # of buildings) + (65 x # of units) = total fee
i.e. (130 x 2 buildings) + (65x 10 total units) _ $260 (buildings) + $650 (units) _ $910 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.
L___
Applicant's Name (print): Signature: 0',\ (*�L j
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