HomeMy WebLinkAboutAPPLICATION - 17-00143 - 3rd S 1st W - BYUI Tennis Court Sprinkler UpdateCITY OF
REXBURG
Americas Family Community
Building Safety Department
BUILDING PERMITFORM 430 City of Rexburg
0pdaiad 212017 35 North 1St East
BUILDING APPLICATION
Miscellaneous Plumbing Work
Rexburg, Idaho 83440
For Office Use
Permit Number: -Ufl aj ❑ Plumbing Fees Paid
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1. Property Owner
Name: 1914 U __r_
Address.y15�-5 City: State: 2-0 Zip Code:
Phone: 26g- Email: Wtl y\, 14Ut 4d U.
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 section 4 of this application and complete the Homeowner's Exemption page as well)
No, l am working with the homeowner
2. Plumbing Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: 5 A5 +- h4 wtate License #: V /� WTS �
Address: G City �S�2aA1FU i(] State: Zi,P Code:'t-b O)
Phone: 6d, cV-' 2-o Email: Vie -F
Contact/Rep. Name: Aa�� \nPhone: •lo`d0-lP0irl0Email:avtciASIL2R_au® a61.✓i•�
Plumbing Contractor Authorized SignaturF +� � `pg � Date:
A copy ofyour state registration/license is required to be on file. If this is the first timeyou have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on fle please check with the Permit Technician by calling (206) 372-2341.
3. Project ^Description
Address: YGIK'Ct�t' UKWZ010550610 -OR- Lot M Block M Subdivision:
What type of Property: ❑ Residential A4 Commercial
Cost of job: $9 V� ODO
Description of work: �;at��k� ef- SUSf SIM F1�S �1 LIGI't"1 0\4
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
)1K Lawn Sprinklers/Backflow device = $65 Inspection fees can be bundled upon request. Re-inspectfees will be
❑ Gray Water Systems =$130 enforced if inspection requests exceedfeetotals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that l have read this application and state that theinformation 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
Cityto 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 offact 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.
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Applicant's Name (print)�X I6tAyktyn Signature: Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests dd 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