HomeMy WebLinkAboutAPPLICATION - 17-00328 - 35 W Main - Plumbing RemodelF;OQ p¢xeppCb
CITY OF
�` ° �imG BUILDING PERMIT FORM 331
urmua RM
rlv
Ameriods family Community
BUILDING APPLICATION
Remodel Plumbing
Building Safety Department
City of Rexburg
35 North 11t East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Plumbing Fee Paid
1. Proper!Owner
Name:n �y7
Address' - G/ ' �-� f City: State: t b Zip Code: 7
Phone: a.D 8 -!;—gI' GSS( Email:
2. Electrical Contractor D/
Business: nQ 17 ^'� T /� +rd : S < State License #: a4 6 S Exp.: �D
Address: S- -) r City: �1 =l c 4. 1s I -L State: I- Zip Code: R 3 !YLI 6 Q
Phone: `%6"_,S -b1 - � Email: ) 'c or
Contact/Rep. Name: G L Phone: o11- 06r Email: 7/7
Plumbing Contractor Authorized Signature: Date: S 1
A copy ofyour state registration/license is required to be on file. If this is the first time have done work in the City of Rexburg, please provide
a photocopy ofyour license. Ifyou are unsure ifyour license is on file, please check wi the Permit Technician by calling (208) 372-2341.
3. Project Description
Address:
Description of work l�f` n�/1 ;G'G� �Y �^ " - Z1
❑ Remodel Cost: A stt-ti" 0
• Feesfor remodels are charge by cost:
o First $10,000 = 2%+$60. From $10,000 to $100,000 = 14'o +$260. Above $100,000 =.546 +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first$10,000 and 146 of the remaining $5,000 = $260 + $50 = $310 total IS
• There will also be a plan review fee totaling 10% of the above fee.
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 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 ofthe 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 work stops for 180 days.
C
t 0_5;&
Applicant's Name (print):/I4l C Cr U L _Signature: Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after SAM will be scheduled for the next business day.
Inspection Hotline- (208) 372.2344 www.rexburg.org Permit Technician -(208) 372.2341