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HomeMy WebLinkAboutAPPLICATION - 19-00399 - 614 Lilac - Mobile HomeCITY O F REXBURG America's Family Community For Office Use Permit Number: E 1 - OLt cj BUILDING PERMIT FORM 403 Updated 10/2016 MOBILE HOME APPLICATION Building Safety Department City of Rexburg 35 North 1St East Rexburg, Idaho 83440 ❑ Fees Paid 1. Owner Name:(. �/C /j0am Address: City: ���� State: V Zip Code: <J¢2J`C Subdivision: t o 0 Uri ( Plot: Phone: 435 y C + S SL Email: t (f i4t•6A� Me 2. Contractor j j i Business Name: IA"o ���`S U►.tbt �C� Contact/Rep Name: License # Address: S %`id ��0.0 � City: e,� O State: _Zip Code: O 3 Phone:209 S ( T-745 Email: "IoL'c'1-t(D��M��r©a((�c���. CocM 3. Structure Information Year Built: a -01 -ft- Being moved from (City/County/State): 6. Fees: Check one: ❑ New Mobile Home Tie -downs = $65 ❑ New Mobile Home all Inspections (without gas line) = $195 ❑ New Mobile Home all Inspections (with gas line) = $260 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. i Applicant's Name (print) �MM�'�. -Signature-:----?requests — Date: `� Z Inspections must be called in before 8 AM on the day the inspection is requested. Inspcalled m after 8 AM will b scheduled for the next business day. Inspection Hotline - (208) 372.2344 www.rexburg.Permit Technician - (208) 372.2341