HomeMy WebLinkAboutAPPLICATION - 17-00314 - 57 E Main St - Bathroom RemodelCITY OF
REXBURG
Americas Family Community
BUILDING PERMIT FORM 301
upezha 10/2016
BUILDING APPLICATION
MFR Remodel
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: 1-4 `D6 314 Application Fee: ❑ $100
Prop
Name:!�eOwner,V�
Address: 57 t A44-! h . 9T, City: State: _Ir -2 Zip Code: !i3 U Nl)
Phone: 7—ObEmail:
2. Applicant
Name: Role: (Owner, Tenan(Contractor, tc.)
Address: City � to e: Zip Code: Zn
Phone: Email:
Contact/Rep. Name:
3. General Contractor
Under Idaho Building Code, a registered contractor must do the work far a Commercial Building.
Name: t C,pjos,,T� Registration #: T 3 7,74 Exp.:
Address (n 'L 7�_�j City �State: XFz Zip Code:
Phone: Email:
Contact/Rep. Name: Phon-�-ll.l Email: �-
General Contractor Authorized Signature: A A A Date:
A copy ofyour state registration/license is required to be on file. If this is t e first timeyou hav ne 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 (208) 372-2341.
4. Project Description
Address:
Description of Work:
Project Description:
• Total cost of project -materials and labor: $
• Check all that apply:
❑ Mechanical: Cost $ ❑ Electrical: Cost $ ❑ Plumbing: Cost $_
❑ Fire Alarm: Cost $ ❑ Fire Sprinkler: Cost $
Note: Any contractors involved will need to fill out their respective application.
Building Permitfees for MFR remodels are charged by cost. The application fee applies towards the total fee. For details on how fees are
calculated please check with the building department. There will also be a plan review fee totaling 10% of the permit fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that l have read this application and state thatthe 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. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print)�� Signatur --. 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 www.rexburg.org Permit Technician - (208) 372.2341
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