HomeMy WebLinkAboutAPPLICATION - 17-00338 - 17 S 3rd E - Sewer Line RepairCITY OF
1 EXBIMG BUILDING PERMIT FORM 430
h+ up&.d 10/2016
Americsi Family Community
BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Plumbing Fees Paid
1. Property Owner
Name: M/���/� p
Address:/�/r S e� 4, City: State:2ZipCode:
Phone:,g q — 01 / L4 Email:
Under Idaho Building Code, a homeowner is allowed to do work on their awn home.
Are you a homeowner doing work on your own home?
❑ Yes (Skip to #4 and complete the Homeowner's Exemption)
o, I am working with the homeowner
2. Plumbing Contractor C 11
Under ldaho Building Code, a registered contractor must do the work fora Commercial Building.
Business: Cp•:
C�_ tate Li #: Ex Q /
cense
Address: 6 0_14 City: Fit State: Zip Code: V
Phone: Email:
Contact/Rep. Name:
Phone: 5 q Email: C 6- qwlatj
Plumbing Contractor Authorized Si2nature: Date: iO
A copy afyour state registration/license is required to be on file. If this is the first time you have done work in the CRY of Rexburg, lease provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: 10 Residential ❑Commercial 4 ,_ „[ �Q� I_ , , /
Cost of job: $ �7rt : I—�>(� I��'u� 1
Description of work:
4. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating = $65 + ($10 x # of
`❑ Water Heater = $65 manifolds/zones) = $
/❑7— Sewer Line = $65 ❑ Miscellaneous/Requested inspection = $65
Water Line = $65 ❑ Sewer Turnaround (septic to city) = $65
❑ Lawn Sprinklers/Backflow device= $65 Inspection fees can be bundled upon request Re-inspectfees will be
❑ Gray Water Systems= $130 enforced if inspection requests exceed fee totals.
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APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury,Ihereby certify that l 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 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 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. Permit void if(wark stops for 180 days... 'J
Applicants Name (print)y �T/F!t Signature: Date: /
L� /
Inspections most be called in before 8 A 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