HomeMy WebLinkAboutWORK ACCEPTANCE FORM LEGACY ELECTRIC - 19-00145 - 859 S Yellowstone - Suite 3201 - Henry's Fork Plaza - Commercial Office BuildingContractor Work Acceptance Form
Business Name:*
Contact Name:*
Mailing Address
Email:*Phone:*
Mobile:
Discipline:*License #:*Expiration Date:*Value of Work:
Permit Number:*
Project Name:*
Project Address:*
By signing, I acknowle dge that I am the indicate d contractor for the abov e me ntione d Pe rmit/Proje ct.
Signature Date
Contractor/Subcontractor
legacy electric
ryan leishman
City
rexburg
State / Province / Region
id
Postal / Zip Code
83440
Country
Update new contact information that is not already on file with the City of Rexburg
Street Address
4455 jud st
Address Line 2
ryanleishman@msn.com 2083903306
Electrical 35219 9/30/2019 $
Permit Information
Please enter in the following format: 00-00000
19-00145 bart stevens
859 s yellowstone
Acceptance
Sign 9/26/2019