HomeMy WebLinkAboutAPPLICATION - 19-00675 - 162 W 4650 N - Gas Line04 ggXB URG
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31 N 1st E
J>> ° Rexburg Building Department Rexburg, Idaho 83440
Ph: (208)372-2160
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eo Mechanical Permit Application rexburg.orci
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Please fill out this application completely and submit with payment. If you have questions or need assistance completing the application, please call the
Rexburg Building Department. Please note: permit fees are non-refundable and non -transferable.
1. Property�Owner _
Name:/
Addressl r �/d 7 &1 S-0 City: State: !/ Zip Code:
Phone: 2Osp5. / 3 5 cS' / Email
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: State License #: Exp.:
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
Mechanical Contractor Authorized Signature: Date:
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 ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2160.
DESCRIPTION OF WORK: A%D
JOB SITE ADDRESS: cc. h Z
CITY
DIRECTIONS TO JOB SITE:
ZIP:
AN ADDITIONAL $65 FEE MAY BE ASSESSED if a re -inspection on the project is required.
COUNTY:
THIS PERMIT APPLICATION IS NOT AN INSPECTION REQUEST: To schedule inspections please call (208) 372-2344
It is the responsibility of the permit holder to arrange access to the premises with the property owner in order for the city
to complete the inspection.
We Accept: cash, check, money order, Visa and MasterCard. GRAND TOTAL FEES PAID*
Make checks payable to the City of Rexburg
*Please use the worksheet on page 2 to determine the total fees and enter the amount to be paid here.
PUBLIC RECORDS NOTICE — Business information such as your company address and phone number is regarded as public information
according to the Idaho Public Records Act. Your business address and phone number may be provided to a third party upon written request.
DATE: /�
SIGNATURE: ���"Z _,�-- PRINTED NAME: Gi'1 C) k,j'
Page 1 Revised 7/08/2019