HomeMy WebLinkAboutAPPLICATION - 17-00026 - 344 W 4th S Ste - Central Storage Salon - Sink AdditionC I TY OF
,G BUILDING PERMIT FORM 43
Updated 10/2016
Building Safety Department
City of Rexburg
35 North 1St East
AnrerlcasFamily Conununily Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Plumbing Work
For Office Use
Permit Number: ❑ Plumbing Fees Paid
1. Property Owi Cl'
Name �� t � 64o
Address: S `�� �� —/A a . �t+," �C- City: ��� r�,�'<' State: Zip Code:
Phone: 20b, Z6 /25-6 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)
®,No, I am working with the homeowner
2. Plumbing Contractor
Under Idahfo Building Code, a registered contractor must do the work for a Commercial Building.
Business: Ikle5 <'/�G'-��� State License #: t/ - d " #5-1 %Exp.:
Address: "f Z—� Rn City: State: a7� Zip Co
�EmalPhone: 7 e, s
✓_' (i F
Contact/Rep. Name:® Phone: dc`f 5` f3 Email: -71-15 It +
Plumbing Contractor Authorized Signature: �js/= f' - Dater
A copy ofyour state registrationflicense is required to be oil file. if this is the first tine 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 Description
Address: '5�s re 4y i �� -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ,Commercial
Cost of job: $ 600
Description of work: "✓ri'Y t %`'�° �'`�
4. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating= $65 + ($10x # 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.
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. 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 n which the Fermi our approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print):`��� �Signature: 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.t-exburg.org Permit Technician - (2 08) 372.2341