HomeMy WebLinkAboutAPPLICATION - 16-00805 - 915 Westwood - Water Heatervppxeuxc
CITY T Y OF
BUILDING PERMIT FORM 430
CUP
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Amedeek Randir Connmmity
BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 151 East
Rexburg, Idaho 83440
For Office Use
Permit Number: (6 �QLL ' S Plumbing Pees Paid
1. Proerty n-ner
Name GLi�+ .e Molvorn
Address Q (S Wes V 700 City: G btu Stater—Zip Code; �3
Phone:�'$O � - 2- ta! 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 Homeowners Exemption)
VMo, I am working with the homeowner
2. Plumbing Contractor
Underfdaho Building Code, a registered contractor must do the workfor a Commercial Building,
Business: Fi �1 dl �'P f u Sta Lice se #:'��'6-I-11;171 Exp.:
Address: (i� l -t rrb r city: J State: _ Zip Code: '934101
Phone: S Z' 7 Email:
Contact/Rep. Name: h�G — Phone: tt Email: ri4U2a&yrZLrA1L2t
Plumbing Contractor Authorized Signature: Date: I z (a / ( b
A copy ofyour state registration/license is required to be of file. if this is the first timeyou have done work in the City of Rexburg, please provide
a photo copy of your license. ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Do I ;�
Address: GI (S k%� 1(r1 r6a 1 ] r -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: wesidential ❑ Commercial
Cost of job: $
Description of work: ur� kf'F� IY
4. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating= $65 + ($10 x # of
.247. 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 Inspectlon 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, l hereby certify that I have read this application and state that the information herein
is correct and I swear that arty information which may hereafter be given by mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg
shall be truthful and correct Iagree to comply with all City regulations and State laws relating to the subject matter ofthis application andhereby authorized representatives afthe
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 ofany false statement or misrepresentation of (actin the application *theplanswhich ah 'permit or approval was based. Permit void Ifnot
started within 180 days. Permit void lfwark stopslfor 180 days.I,�Applicant's Name (print): n Y'IC-V Signature: Date:Inspections must be called in before 8 AM on the day the inspection is requested. Insped in aft Il be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.mxburg.org Permit Technician- (208) 372.2341