HomeMy WebLinkAboutAPPLICATION - 19-00487 - 100 Marigold St - Mobile HomeOQ V. BV
f7 CITY OTTF Building Safety Department
° RE URG BUILDING PERMIT FORM403 City of Rexburg
cy, Updated 10/2016 35 North 1St East
'•<„.Americ4 Family Community
Rexburg, Idaho 83440
MOBILE HOME APPLICATION
For Office Use
Permit Number:
❑ Fees Paid
I. Owner
Name:
Address: City: 'X LJ �L State:. -/.4
��// _� Zip Code:
Subdivision: I./I' �4 /�r�� Gaff "Vu /7-y plot: /c
Phone: ',-C l % /(s Email:r�
2. Contractor
Business Name:
Address:
Phone: Email:
3. Structure Information
Year Built: 0-0 (Z- Being moved from
6. Fees:
Check one:
Contact/Rep Name:
City:
❑ New Mobile Home Tie -downs = $65
New Mobile Home all Inspections (without gas line) = $195
❑ New Mobile Home all Inspections (with gas line) = $260
License #
State: Zip Code:
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, 1 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): D1914 6L G) . A �
Ignature: 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