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HomeMy WebLinkAboutAPPLICATION - 17-00232 - 347 Salem Ave - Water Line ReplacementCITY OF REXBURG r� Ameriroirwmily community Building Safety Department BUILDING PERMIT FORMCity of Rexburg Uyae[M10i3016 430 35 North 15t East BUILDING APPLICATION Miscellaneous Plumbing Work Rexburg, Idaho 83440 For Office Use , Permit Number: I C>0 c� 3� -9f Plumbing Fees Paid 1. Property Owne Name: IQ4me 'dye Address: .317 4;a1em ' ,A UL City: State: Zip Code: 3 Yr Phone: 07& 3S6_9%3/ Email: Ajc4e, � oFinadrooi 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 HomeAner's Exemption) Cl No, I am working with the homeowner 2. Plumbing Contractor Under Idaho Building Code, a registered contractor must do the work for a Commercial Building. Business: a d l a N State License #: r so, y Exp.: Address: City: State: Zip Code: Phone: XOii - 39d ''7060 Email: Contact/Rep. Name: Phone: Email: Plumbing Contractor Authorized Signature: Date: - A copy ofyour state registration/license is required to be on file. If this is the first 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 (208) 372-2341. 3. Project Descri tion / ,/ Address: 3y Sa/C�✓� OR- Lot #: _Block #: _ Subdivision: What type of Property: XResidential ❑ Commercial Cost of job: $ Description of work: ki rlatL tyge + Ahs& Lime, 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 K 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. APPLICANTS 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. 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 ofthe 2012 International Code in cases ofany 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. A Applicant's Name (print): Slacc Nit Signature: �/ ZJ#C Date: y �� 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