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PLANNING AND BUILDING DEPARTMENT

Mechanical Installation Permit Application

Owners Name: _______________________________________Phone: (_____)____________________

Mailing Address:______________________________________City________State____ Zip Code_____________

_____________________________________________________________________________________________

Applicant (if other than owner) ___________________________________Phone: (_____) ____________________

Mailing Address:_______________________________ City _____________State____ Zip Code______________

Note: If applicant is other than owner, a notarized Teton County Letter of Authorization must accompany this application. Only the owner

or his/her authorized agent may sign either the application, correction list or permit.

Job site address: _______________________________________________________________________________

Parcel Number _________________________

Section:_______

Township: ________

Range:_______

Contractor Information:

Name:_______________________________________________________ Phone(____)_____________________

Company Name: ______________________________________________ Phone(____)_____________________

Mailing Address: _______________________________City _____________State_____ Zip Code_____________

State of Idaho HVAC License Number: ________________________________________

Number of HVAC units to be installed:________

Type:

1. ____________________

Manu. 1. ___________________

2. ____________________

2. ___________________

3. ____________________

3. ___________________

4. ____________________

4. ___________________

Job description: _______________________________________________________________________________

_______________________________________________________________________________

[Provide all necessary information such as heating/cooling calculations, plans, etc.]

OFFICE USE:

Permit No: ____________________

Cost:

$50 each unit = _______________________

Paid by: _____________________________ Date: _______________ Check No:___________

Date Issued: ____________________

By: ________________________

APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby

certify that I have read this application and state that the information herein is correct and I swear that any

information which may be hereafter given by me in hearing before the Planning Commission of Teton County or the

Board of County Commissioners of Teton County shall be truthful and correct. I agree to comply with all county

regulations and State laws relating to the subject matters of this application and hereby authorize representatives of

this County to enter upon the above mentioned property for inspection purposes.

In signing this application, I acknowledge that the County’s acceptance of this application and permit fees does not

constitute approval of the permit. I agree not to commence any work for which this application is being made prior

to approval of this application by the appropriate County agencies and payment of any fees due.

_______________________________________________

___________________________

Signature of Applicant

Date

_______________________________________________

__________________________

Print Name

Title

Mechanical Installation Permit Application Form - Planning And Building Department, Teton County, Idaho

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