HomeMy WebLinkAboutWORK ACCEPTANCE FORM HOUSLEY PUMP INC - 21-00467 - Encompass Health - 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
Housley Pump Inc
Thayne F Goulding
City
St. Anthony
State / Province / Region
Idaho
Postal / Zip Code
83445
Country
United States
Update new contact information that is not already on file with the City of Rexburg
Street Address
40 west main
Address Line 2
hpumps@netscape.net 2086243772
208-390-3774
Plumbing PLB-C-9265 2/28/2024 3,000.00$
Permit Information
Please enter in the following format: 00-00000
21-00467 ENCOMPASS HEALTH
859 S YELLOWSTONE #201
Acceptance
Sign 7/8/2021