HomeMy WebLinkAboutWORK ACCEPTANCE FORM LEGACY ELECTRIC - 20-00075 - 510 N 2nd E - Suite 1 - DMV License - RemodelContractor 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
4455 jud st
Address Line 2
nickleishman@gmail.com 2087160420
Electrical 35219 6/15/2020 12,000.00$
Permit Information
Please enter in the following format: 00-00000
20-00075 dmv
510 N 2nd E, 1
Acceptance
Sign 2/27/2020