HomeMy WebLinkAboutWORK ACCEPTANCE FORM LEGACY ELECTRIC - 19-00590 - Fullmer - Medical 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
nick leishman
City State / Province / Region
Postal / Zip Code Country
Update new contact information that is not already on file with the City of Rexburg
Street Address
Address Line 2
nickleishman@gmail.com 2087160420
Electrical 35219 12/31/2025 85,000.00$
Permit Information
Please enter in the following format: 00-00000
19-00590 Fullmer Medical
28 N 12th W
Acceptance
Sign 1/30/2020