HomeMy WebLinkAboutWORK ACCEPTANCE FORM ELECTRICAL SUPPORT SERVICES - 19-00780 - 500 N 2nd E - DL Evans BankContractor 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
Electrical Support Services
Brent Purcell
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
brentjp@msn.com 208-251-6022
Electrical ele-c-4342 6/30/2021 $
Permit Information
Please enter in the following format: 00-00000
19-00780 DL Evans Bank
50 N 2nd East
Acceptance
Sign 2/26/2020