HomeMy WebLinkAboutWORK ACCEPTANCE FORM LEGACY ELECTRIC - 19-00625 - 545 Henderson St - Kirkpatrick New SFRContractor 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
Madison
Update new contact information that is not already on file with the City of Rexburg
Street Address
4455 Jud Street
Address Line 2
ryanleishman@msn.com 2083590672
2083903306
Electrical ele-c-35219 6/30/2021 13,000.00$
Permit Information
Please enter in the following format: 00-00000
19-00625 Ed Kirkpatrick
545 Henderson Street
Acceptance
Sign 11/5/2019