HomeMy WebLinkAboutAPPLICATION - 17-00075 - 52 E Main - Game Pulse - Electric Water HeaterCITY OF
REXBURG
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Americas family Community
BUILDING PERMIT FORM 430
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BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 151 East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Plumbing Fees Paid
1. PropeYO
Nam.wnear("d\ 6) ,D. S'
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Ciy: SAddress: C : Zip Code: $�
Phone: ���j'�jr]I- ?-Alb 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 #4 and complete the Homeowner's Exemption)
o, I am working with the homeowner
2. Plunfilinj Contractor
Under ldaho Building Code, a registered contractor must do the work jar a Commercial Building.
Business: �k� ?lumb'ina hmoc State License#: PIA C,- I�Exp.:
Address: Y(1 ?,ny rV{Q City: IA State: Zip Code:
Phone: Q mail:
Contact/Rep. Name: Phone:7N°iggN Email: A I'
Plumbing Contractor Authorized Signature: �l�-�/�—�- Date:
,I copy ofyour state registration/license is required to be on file. if this Kthefirst time you have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (2 08) 372-2341.
3. Project Description
Address: 5) E ma to OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential mmercial
Cost of job: $� , 2An
Description of work: –&JJ `IC I,_ r _ I)Ar {10���d
4. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating = $65 + ($10 x # of
Water Heater= $65 manifolds/zones) = $
❑ 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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APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury,I hereby certify that l have read this application and state that the information herein
is coma 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 1 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 ofany false statement or misrepresentation of fad in the application or on the plans on which the permit or approval was based. Permit void if not
staffed within 180 days Permit void If work stops for 180 days. QQ /J
Applicant's Name (print): G ( Signature: Q /'Date:�l
Inspections must be called in before 8 AM on the day the inspection T, 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