HomeMy WebLinkAboutAPPLICATION - 16-00578 - 1032 Larch - SFRCITY OF
REXBURG
C
America's Family Community
Building Safety Department
fj �- 0057 g City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
SINGLE FAMILY RESIDENTIAL APPLICATION CHECKLIST
The following items should be completed before you submit your building permit application.
*Reasonable accommodations will be made upon request
Complete the Following:
J'i 2 sets of site plans (see Site Plan Checklist on page 2)
,A� 2 sets of building plans drawn to scale (see box below) - stamped by a licensed professional
❑ Foundation Plan, Floor Joist Layout, Floor Plan, Roof Layout, Truss Details, Sectional Views, Front,
Back, and Side Elevations, Mechanical Layout, Stair Details, and any details required to illustrate
special construction.)
Structural Calculations (see box below) -stamped by a licensed Engineer
�s Energy Compliance Report: As per the 2012 IECC, a RESCheck is required (available online
atwww.ener codes.gov)
❑ Homeowner's Exemption signed, if Homeowner is doing work on their own home. (see page 4)
Building Permit Application signed by a registered General Contractor. (see page 3)
❑ Mechanical Permit Application signed by a registered Mechanical Contractor. (see page 5)
❑ Electrical Permit Application signed by a registered Electrical Contractor. (see page 6)
❑ Plumbing Permit Application signed by a registered Plumbing Contractor. (see page 7)
❑ Property Line form signed by builder. (see page 8)
❑ Affidavit of Legal Interest signed by owner. (see page 9)
❑ Subcontractor list filled out (see page 10)
Subdivisions: If you plan to build in a subdivision please check the Rexburg Development Code for any
requirements such as, property setbacks, architecture board approval, etc.
This information is available at http://rexburg org/"ages/development-code.
Seismic Design. Category - D
Ground Snow - 50 lbs. per sq. ft.
Roof Snow Load - 35 lbs. per sq. ft
Wind Load 90 MPH
Frost Depth- 36"
Inspection Hotline -(208)372.2344 w rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
I
oQpBxBUg� og CITY OF Building Safety Department
o REXBURG City of Rexburg
c 35 North lot East
America's Family Community Rexburg, Idaho 83440
Permit Policies Acknowledgement
The City of Rexburg Building Safety Department is determined to provide excellent customer service. In an effort to help you
understand the City of Rexburg Permit Policies, listed below are several policies which you are required to know prior to
proceeding with your project:
Any construction within the City of Rexburg which requires a permit shall not begin until an approved permit is
obtained. If you do not have a pink building permit signed by the Building Inspector, then you do not have an
approved permit.
o Building without the pink building permit signed by the Building Inspector will result in double fees to be
assessed and the project to be red tagged. If your project is red tagged, halting all construction, only a City
Initials Official may remove the red tag. If the red tag is removed by anyone but a City Official, citations will be issued.
No building may be occupied without receiving a signed Certificate of Occupancy.
o If a building is occupied without receiving a signed Certificate of Occupancy, citations will be issued and the
occupants will be evicted.
Initials
Calling in inspections is the responsibility of the applicant and their contractor. Inspections need to be called
into the hotline and not to the inspector. Inspections called in later than 8 AM will be scheduled for the following
business day.
o If an inspection is not done, the inspector may require any measures to betaken to allow him to correctly
perform the inspection. (Example: If the electrical rough in inspection is not done and the sheetrock has been
nitiaf is put up, the inspector may require the sheetrock be removed in order to perform the electrical rough in
inspection.)
Any approval for Certificate of Occupancies and Building Permits is only verified through the Permit Technician,
If an inspector says something like "You're good to go", understand that you still need to receive all relevant
documentation from the Permit Technician before you are truly good to go.
o Even if you hear from an inspector that'you're good to go', ultimately if you do not have a Building Permit or
Certificate of Occupancy, the above policies will be enforced.
Initials
It is your responsibility to relay this information on to anyone who this would be applicable to for your project.
All sub -contractors will be held to this standard with no exceptions.
/)[/�j'+❑ o The above policies will be enforced to all, regardless if you pass this information onto them or not
Applicant's Name (print): Z?4 / Signature: Date:
Inspections mustbe called in before 8 AM on the day the inspection is requested. Inspecdon requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
REXBURG
CW
America's Family Community
SITE PLAN CHECKLIST
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
❑ 1 Site plan must be drawn to scale, be legible and also be submitted electronically if possible.
❑ 2. Adjoining streets labeled.
❑ 3. Right-of-way location and width, curb to curb widths and sidewalk location.
❑ 4. Building location, sq footage and dimensions, with distance to property lines and distances
between buildings.
❑ S. Show existing and proposed easements.
❑ 6. Existing utilities (waterlines, sanitary sewer lines, manholes, storm drains).
❑ 7. Proposed utilities including tie in location to existing services and new easements.
❑ 8. Proposed storm drain and sanitary sewer elevations (for pipe inverts at manholes and catch basins).
❑ 9. Storm drainage plan for parking lot and roof areas, with calculations.
❑ 10. Fire hydrants and fire suppression lines (including tie to City lines).
❑ Sprinkled ❑ Not Sprinkled
❑ 11. Indicate Fire apparatus access.
❑ 12. Parking (including parking lot, drainage arrows, dimension of lot, distance between rows, and total
numbers).
❑ 13. Landscaping (type and total area, including dimensions).
❑ 14. Trash facilities.
❑
15.
North Arrow
❑
16.
Drawing to Scale, including a graphic scale (11 V2 x 17" paper if possible).
❑
17.
Proposed street improvements (curb, gutter, sidewalk, pavement, etc.)
❑
18.
Legal description of proposed building site included.
❑
19.
Percent of lot covered by building or paving calculated.
❑
20.
Show 10% snow storage area.
❑
21.
Distance of entrances from street corner indicated.
❑
22.
Current Vicinity Map. (81/2 x 11") at 1" = 300' scale, showing location of the property.
❑
23.
Lighting Plan
SITE PLANS MUST BE COMPLETE AND SUBMITTED FOR REVIEW BEFORE THE PROJECT WILL BE PLACED ON
THE PLANNING & ZONING AGENDA.
Inspection Hotline -(208)372.2344 �.rexhurg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
REXBURG
tW
Americai Family Community
BUILDING APPLICATION
Single Family Residence
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use (_ Digital PlansIncluded: 11 CD 13 USB ❑ Dropbox 13 Not Included
Permit Number: 1V - 005'7$ Permit Type: )KNew ❑ Remodel ❑ Addition ❑ Basement Finish
DepositAmount}($500 New Const O $100 Other than New Const. Deposit Included with Application: )KYes❑ No
1. Prope�!prv• Owner �
Name: Lr�i' %il ks I kCrs
Address: C C l'/r. City: ✓`G4e-n State: I/7 Zip Code: -0
Phone&Type: %W ❑Office'KMobile Email: //n
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)o No, I am a contractor working for the homeowner
NOTE: Any contractors/sub-contractors involved will need to submit their own signed applications.
2. Applicant
Name: SG1rr1Y,� Role: (Owner, Tenant, Contractor, etc.)
Address: City: State: Zip Code:
Phone & Type: ❑ Office ❑ Mobile Email: _
Contact/Rep. Name: Phone: Email:
3. Getter /
Name: 4 ZL1(/f(� R istration#: '
al ntractor Exp.:_�1
Address:'3 City: State: _/,:k Zip Code:
Phone &Type: dX75' ❑Office�°Mobile Email: /ar��aJnn�Sbvi/_.Ld
Contact/Rep. Name: / _Phone: to `755�/-/W Email: .
General Contractor Authorized Signaturei Date: 9 7u-/
4. Project Description
Address: _ OR- Lot #: Block #:1 Subdivision: �/�Jl�1fY/nJ
Type of woc
Check one: New Construction ❑ Remodel* ❑ Addition* ❑ Basement Finish*
*Check all that apply: Framing XMechanical RPlumbingVElectrical
NOTE: Any sub -contractors involved will need to submit/ th�eir own signed applications.
*Description of work: )Y_ . ) yylY17/Ys
*Total cost of project - materials and labor: /$ZOLO, EOtl (used to calculate permit fees)
Building Total: _ sq. ft. Main: -1sq. ft. Basement: Finished 13 Unfinished sq, ft.
Garage q 7x— sq. ft. Additional Floors: sq, ft,
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that l have read this application and state that the infarmation herein
is correct and I swear that any information which may hereafter be given by mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct I agree to comply with all City regulations and State laws relating to the subject matter ofthis application and hereby authorized representatives ofthe
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions of the 2012
International Cc de in cases ofany false statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Pernitvoidifnot
started within 180 days. Permit void if work stops for 180 days. t
Applicant's Name (Print):06.e_Signature: Date:
Inspections most be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Tecimician-(208)372.2341 Revised March, 2016
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� �CITY
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Americas Family community
EXEMPTIONS FROM STATE REGISTRATION
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
As of January 1, 2006, the City of Rexburg can no longer sell permits without having a copy of your State
registration number or your exemption from the State registration. Please send a copy of your state registration or
fill out this form showing your exemption and send it with your license renewal or your next permit application.
(This list is a summarization of Idaho Code Title 54 Chapter 5205, for full definitions of these exemptions please
see the State's website at www.ibol.idaho.gov/cont.htm)
❑ Currently State licensed pursuant to Title 54 Idaho Code, Chapters:
3 Architects,
10 Electrical Contractors/Journeyman,
12 Engineers/Surveyors,
19 Public Works Contractors (exempt from fee only registration required),
26 Plumbing/Plumbers,
45 Public Works Construction Management Licensing Act (exempt from fee only registration required), or
50 Installation of heating, ventilation and air conditioning systems
❑ Employee or volunteer of a licensed contractor or part of an educational curriculum or nonprofit charitable
activity with no wages or salary
❑ Employee of a US Government agency (State, City, County, or other municipality)
❑ Public Utility doing construction, maintenance, or development to its own business
❑ Involved with gas, oil or mineral operations
❑ Supplier doing no installation or fabricating
❑ Contracting a project or projects with a total cost less than $2000
❑ Operation of a farm or ranch or construction of agriculture buildings exempt from Idaho Building Code
❑ Any type of water district operations
❑ Work in rural districts for fire prevention purposes
❑ Owner who performs work on own property or contracts with a registered contractor to do work as long as the
property is not for resale within 12 months
❑ Owner or lessee of commercial property performing maintenance, repair, alteration or construction on that
property
❑ Real estate licensee/property manager acting within Idaho Code
❑ Engaging in the logging industry
❑ Renter working on the property where they live with the property owners approval
❑ Construction of a building used for industrial chemical processing per Idaho Code
❑ Construction of a modular building (defined by Idaho Code) to be moved out of state
1 hereby certify that the above information is true and correct to the best of my knowledge.
Signature
Date
Print Name
Inspection Hotline -(208)372.2344 w .rexhurg.org Permit Technician -(208)372.2341 Revised March, 2016
�;O AE%BURCty
CITY OF
REXBURG
Amenw' Famffy Community
Affidavit of Legal Interest
State of Idaho
County of Madison
1,
Name
City
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
Address
State
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
A. That I am the record owner of the property described on the attached, and 1 grant my permission to:
Name
Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any claim or liability
resulting from any dispute as to the statements contained herein or as to the ownership of the property
which is the subject of the application.
Dated this
day of 20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Inspection Hotline -(208)372.2344 w .rexhurg.org Permit Technician -(208)372.2341 Revised March, 2016
� l
CITY OF Building Safety Department
0 o REY.BURG City of Rexburg
C 35 North 1st East
Americas Family Community Rexburg, Idaho 83440
Property Lines
Each site plan that is submitted to the City of Rexburg for the Building Permit process requires that property lines
are shown accurately. It is the Developer's responsibility to correctly identify on the site plan the location of these
lines in reference to the public right-of-way, other adjoining property lines, the street, other structures and all
utility lines. The Developer should find property pins that are still available at the lot in question. If these pins do
not exist or have become unrecognizable then a new survey should be performed.
Accurate property line information is a must for a timely review. In addition to finding existing property pins, legal
descriptions should be checked. The best way to identify property line location is with a land survey. The City of
Rexburg has aerial photos and a parcel line layer that can be checked, but they are only a tool and are not
guaranteed for accuracy. If you want to request a copy of your lot, see the front counter at the Community
Development Department.
I have read and understand the above requirements.
Oze.46�2,d �ir!��'.r��
Printed Name
Date
Inspection Hotline -(208)372.2344 wvnv.rexburg.org Permit Technician -(200)372.2341 Revised March, 2016
CITY OF
POWURG
nv
America!; Family Community
BUILDING APPLICATION
Mechanical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: Permit Type: ❑.New.❑Remodel ❑Addition ❑Basement Finish
Fees Paid: D Yes []No
1. Property Owner
Name:
Address: City: State: Zip Code:
Phone &Type: D Office O Mobile Email:
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home? ❑ Yes (Skip to #3 and complete the Homeowner's Exemption page)
D No: I am a contractor working for the homeowner D No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contractors/sub-contactors involved will need in submittheir own signed applications.
2. Mechanical Contractor
Name: Registration #: Exp.:
Address: City: State: Zip Code:
Phone & Type: D Office D Mobile Email:
Contact/Rep. Name: Phone: Email:
Mechanical Contractor Authorized Signature Date:
3. Project Description
Address: -OR- Lot #: _ Block #: —Subdivision:
Check one: ❑ Single-family Residence D Multi -family Residence D Commercial
Check one: D New Construction* D Remodel D Addition D Basement Finish
Description of work: _
New Commercial Work: Contracted amount: $ Calculated Fee (See Below):
D Up to $10,000 = (total cost of system x.02) +$60 D $10,0014100,000 = ((total cost of system -10,000) x.01) + $260
D Over $100,001 = ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: _ Sq. Ft
D Up to 1,500 Sq. Ft. = $130 D 1,501-2,500 Sq. Ft = $195 D 2,501-3,500 Sq. Ft = $260 D 3,501-4,500 Sq. Ft = $325
[]Over 4,500 Sq. Ft = $325+(65 x # of additional 1,000 Sq. Ft. (or portion thereof)) $
New Multi -Family Residential: D Duplex= $260 D Three or more units= $((130 x# of buildings)+(65 x #of units))$_
New work on any other residence and Detached Shops:.= $(65 + (10 x # of HVAC fixtures))
Miscellaneous: DGas.Pressure =$65 ❑ Furnace orA/C = $65 D Water Heater =.$65 D Requested Inspection= $65
OGas Line = $65 D Fireplace/Solid Fuel Burning Unit= $65 'O Technical Service= $65/hour
D Plan Check =10% of Contracted Amount
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Underpenalty ofpedury, I hereby certify that l have read this application and state thatthe information herein
is correct and I swear that any infonnatlon which may hereafter be given by me in hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthfuland correct. I agree to comply with all City regulations and State laws relating to the subject matter of this application and hereby authorized representatives ofthe
City to enter upon the above-mendoned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions ofthe 2012
International Code in cases ofany false statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Permit voidifnot
started within 180 days. Permit void ifwork steps for 180 days.
Applicant's Name (print):
Signature:
Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 wvov.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
RMURG
na,
Ameruds Family Community
BUILDING APPLICATION
Electrical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number:_ PermitTyper ❑ New []Remodel ❑ Addition ❑Basement Finish
Fees Paid: ❑ Yes ❑ No
1. Property Owner
Name:
Address: City: State: Zip Code:
Phone &Type: ❑ Office ❑ Mobile Email: _
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home? ❑ Yes (Skip to #3 and complete the Homeowner's Exemption page)
❑ No: I am a contractor working for the homeowner ❑ No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contracmrs/sub-rontraaors involved will need to submutheir own signed applications.
2. Electrical Contractor
Name: Registration #: Exp.:
Address: City: State: Zip Code:
Phone & Type: Cl Office O Mobile Email:
Contact/Rep. Name: Phone: _ Email:
Electrical Contractor Authorized Signaturej: _ Date:
3. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
Check one: ❑ Single-family Residence O Multi -family Residence []Commercial
Check one: ❑ New Construction* ❑ Remodel ❑ Addition ❑ Basement Finish
Description of work:
New Commercial Work: Contracted amount: $ .Calculated Fee (See Below): $
❑ Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,001$100,000 = ((total cost of system -10,000) x.01) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: Sq. Ft
❑ Up to 1,500 Sq. Ft. = $130 ❑ 1,501-2,500 Sq. Ft = $195 ❑ 2,501-3,500 Sq. Ft = $260 ❑ 3,501-4,500 Sq. Ft = $325
❑ Over 4,SOO Sq. Ft = $325+(65 x # of additional 1,000 Sq. Ft (or portion thereol)) $
New Multi -Family. Residential: O Duplex= $260 ❑ Three or more units= $((130x# of buildings)+(65 x # of units))$
New work on any other residence and Detached Shops: = $(65 + (10 x # of branch circuits)) $
Miscellaneous: ❑ Small Works (work costing less than $200 with no change in service connections) =$10 no inspection.
❑ Central Heating/Cooling Systems $65 ❑ Spas, Hot Tubs, and Swimming Pools= $65 ❑ Requested Inspection= $65
❑ Pumps Water, Irrigation, Sewage (per motor) = ❑ $65 up to 25HP ❑ $95 26- 200HP ❑ $130 over 200HP
❑ Irrigation Machine = $65 for center pivot+ $10per tower of drive motor$ ❑ Technical Service =$65/hour
❑ Temporary Amusement = $65 + $10 per ride, concession, or generator $ ❑ Plan Check =10% of Contracted Amount
❑ Temporary Construction Services ONLY = $65 200 am or less. One location for less than 1 ear.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, l hereby certify that I have read this application and state thatthe information herein
is correct and I swear that any information which may hereafter he given by mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct. I agree to comply with all City regulations and State laws relating to the subject matter ofthis application and hereby authorized representatives ofthe
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions ofthe 2012
International Code in cases ofany false statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Permitvoidif not
started within 100 days. Permit void Hworkstops for 160 days.
Applicants Name (print): Signature: Date
Inspections most be called in before a AM on the day the inspection is requested. Inspection requests called in after B AM will be scheduled for the next business day.
Inspection Hodine - (2 08) 3 72.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
fg9%6URC
CITY OF
° RMURG
CW
Amerkak Family Community
BUILDING APPLICATION
Plumbing
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number:. Permit Type: ❑. New ❑ Remodel ❑ Addition ❑ Basement Finish
Fees Paid: ❑ Yes. []No
1. Property Owner
Name:
Address: City: State: Zip Code:
Phone & Type: ❑ Office O Mobile Email:
Under Idaho Building Cade, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work on your own home? ❑ Yes (Skip to #3 and complete the Homeowner's Exemption page)
❑ No: I am a contractor working for the homeowner ❑ No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contractors/subcontractors involved will need to submit their own signed applications.
2. Plumbing Contractor
Name: _ Registration #: Exp.:
Address: City: State: Zip Code:
Phone & Type: ❑ Office ❑ Mobile Email:
Contact/Rep. Name: Phone: Email:
!Plumbing Contractor Authorized Si natured Date:
3. Project Description Water Meter Quantity: Water Meter Size:
Address: -OR- Lot #: _ Block #: _ Subdivision:
Check one: ❑ Single-family Residence Cl Multi -family Residence ❑ Commercial
Check one: ❑ New Construction* ❑ Remodel ❑ Addition ❑ Basement Finish
Description of work:
New Commercial Work: Contracted amount: $ Calculated Fee (See Below): $
Cl Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,0014100,000 = ((total cost of system -10,000) x.01) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: Sq. Ft
❑ Up to 1,500 Sq. Ft. = $130 ❑ 1,501-2,500 Sq. Ft = $195 ❑ 2,501-3,500 Sq. Ft. = $260 ❑ 3,501-4,500 Sq. Ft = $325
❑ Over 4,500 Sq. Ft = $325+(65 x # of additional 1,000 Sq. Ft (or portion thereof)) $
New Multi -Family Residential: ❑ Duplex= $260 ❑ Three or more units= $((130 x #.of buildings)+(65 x # of units))$_
❑ Gray Water. Systems= $130 ❑ Lawn Sprinklers/Backflow device=. $65 []Multipurpose Fire Sprinkler & Domestic Water
Supply System= $65 or $4 per sprinkler head (whichever is eater
New work on any other residence and Detached Shops: = $65 for sewer and water stub connections
Miscellaneous: l7 Sewer Line = $65 ❑ Water Line = $65 ❑ Sewer and Water Line= $65 ❑Requested inspection= $65
❑ Sewer Turnaround (septic to city)= $65 ❑ Hydronic Heating= $65 + ($10 x # of manifolds/zones)
❑ Technical Service =$65/hour []Plan Check =10% of Contracted Amount
APPLICANT'S 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 hereafter be given by me in hearings before the Planning and Zoning Commission or the Qty Council for the City of Rexburg
shall be truthful and correct. I agree to comply with all City regulations and State laws relating to the subject matter of this application and hereby authorized representatives ofthe
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions ofthe 2012
International Code in cases ofany false statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Permitvoid ifnot
stattedwithin 180 days. Permitvmdifwork stops for 180 days.
Applicant's Name (print):
Signature:
Date:
Inspections mustbe called in before 8 AM on the day the inspection is requested. Inspection requests called inafter 8 AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016