HomeMy WebLinkAboutAPPLICATION - 17-00331 - 900 Elizabeth St - Water LinencF
CITY OF
America's Family Community
BUILDING PERMIT FORM 4 3 0
Updated lq/2g1G
BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
3S North 15C East
Rexburg. Idahn 83440
For Office We
Permit Number: ❑ Plumbing Fees Paid
I.- Property ow r
N A�1��
Name: y2-
Address: 200 l zC� i 1 `42-- 13+ke -1 City: �' State: :I_01_Zip Code: �14�f�
Phone: _�i� 17? 0 7 - Email:
Under Idaho Building Code, a homeowner is allowed to do work on their own home.
Are you a homeowner doing work an your own home?
❑ Yes (Skip to #fl and complete the Homeowner's Exemption)
Ergo, I am working with the homeowner
2. Plumbing Contractor.
Under Idaho Building Code, a registered contractor must do the wor for a Commercial Building.
Business: 1152WhLz State License #: 0 - 8 Exp.: 3L a s-kpUl
Address:, i
City: 1 r~ State: Zip Code: � .�
Phone: &- - (ijD. � •- 7 � a� Email:
Contact/Rep. Name: { J Phone: ��1 email: 4 C u
Plumbing Contractor Authorized Signature, Date!�P,0,;
A copy ofy urstate reyistrotionlhCense is regtufred to be ortfile. If this is thefirs Imeyoaf h done work in the City afRexbur ,de
a photo copy ofyour license. lfyou are unsure ifyour license is on file, please check with the eraiit 'Technician by coiling t208) 372-2341.
3. Project Description
Address: a ell Melo e t e"LiL -OR- Lot #: Block #: Subdivision:
_
What type of Property: M-Kesidential O Commercial
Cost of job: $
Description of work:R1
4. ,Fees: Check all that apply:
❑ Gas Line = $65
0 Hydronic Heating= $65 + ($10x# of
Water Heater = $65
manifolds/zones) = $
❑ Sewer Line = $65
Miscellaneous/ Requested inspection = $65
M` -Water Line = $65
11
6 Sewer Turnaround (septic to city) = $65
❑ Lawn Sprinklers/Backflow device = $65
Cnspe
❑ Gray Water Systems= $130 enforced
Iran fees can be bundled upon request Re-inspectfees will be
if inspection requests exceed fee totals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperiury, [ 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 mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct 1 agree to comply withal[ City regulations and State laws relating to the subject matter of this application and hereby authorized representatives of the
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 Code in cases of any false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not
started within 180 days. Permitvoid ifworkstops for 180 days.
Applicant's Name (print): `�� `7f Signature: ` z�C Date: -
Inspections mustbe 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 Technician- (208) 372.2341