HomeMy WebLinkAboutAPPLICATION - 16-00599 - 285 S 1st W - Kimball Remodel Rooms 170, 244, 250i
CITY OF
REXBURG
America's Family Community
Submit By Emall
Permit Policies Acknowledgement
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
The City of Rexburg Building Safety Department is determined to provide excellent customer service. In an effort to help you
understand the City of Rexburg Permit Policies, listed below are several policies which you are required to. know prior to
proceeding with your project.
Any construction within the City of Rexburg which requires a permit shall not begin until an approved permit is
obtained. If you do not have a pink building permit signed by the Building Inspector, then you do not have an
approved permit.
TL o Building without the pink building permit signed by the Building Inspector will result in double fees to be
assessed and the project to beredtagged.-If yourproject isredtagged, halting all construction; only a City
Initials Official may remove the red tag. If the red tag is removed by anyone but a City Official, citations will be issued.
No building may be occupied without receiving a signed Certificate of Occupancy.
TL o If a building is occupied without receiving a signed Certificate of Occupancy, citations will be issued and the
occupants will be evicted.
Initials
Calling in inspections is the responsibility of the applicant and their contractor. Inspections need to be called
into the hotline and not to the inspector. Inspections called in later than 8 AM will be scheduled for the following
business day.
o If an inspection is not done, the inspector may require any measures to be taken to allow him to correctly
TL perform the inspection. (Example: If the electrical rough in inspection is not done and the sheetrock has been
Initials put up, the inspector may require the sheetrock be removed in order to perform the electrical rough in
inspection.)
Any approval for Certificate of Occupancies and Building Permits is only verified through the Permit Technician.
If an inspector says something like "You're good to go", understand that you still need to receive all relevant
documentation from the Permit Technician before you are truly good to go.
TL o Even if you hear from an inspector that'you're good to go', ultimately if you do not have a Building Permit or
Certificate of Occupancy, the above policies will be enforced.
Initials
It is your responsibility to relay this information on to anyone who this would be applicable to for your project.
All sub -contractors will be held to this standard with no exceptions.
TL o The above policies will be enforced to all, regardless if you pass this information on to them or not
Initials
Applicant's Name (print): Terse Larsen Signature: Date: 9/1/2016
Inspections must be called in before B 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 vnvw.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
REXBURG
tn,
America's Family Community
Submit By Email
BUILDING APPLICATION
Commercial/Multi-family Residence
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use Digital Plans Included: ❑ CD ❑ USB ❑ Dropbox ❑ Not Included
Permit Number: f�° —tae Sq9 _ Permit Type: ❑ New ❑ Remodel ❑ Addition
DepositAmount: ❑ $1000 New Const ❑ $250 Addition ❑ $100 Other Deposit Included with Application: ❑ Yes ❑ No
1. Property Owner
Name: BYU-Idaho
Address: Kimball Building City: Rexburg State: Idaho Zip Code: 83460-8205
Phone &Type: 208-496-2662 OOffice ❑Mobile Email: larsent@byui.edu
Under Idaho Building Code, a contractor must do the work for a Commercial Building.
2. Applicant
Name: BYU-Idaho Role: (Owner, Tenant, Contractor, etc.) owner
Address: 525S.Center City: Rexburg _State: Idaho Zip Code: 83460-8205
Phone & Type: 208-496-2662 ❑ Office ❑ Mobile Email: larsent@byui.edu
Contact/Rep. Name: Terrie Larsen - Phone: 208-681-0255 Email: larsent@byui.edu
3. General Contractor
Name: Registration #: _ Exp.: _
Address: City: State: Zip Code:
Phone&Type: _❑ Office ❑Mobile Email:
Contact/Rep. Name: _ _ Phone: Email:
General Contractor Authorized Signature:] Date: 9/1/2016
4. Project Description
Address: Kimhall Building -OR- Lot #: _ Block #: _ Subdivision:
Type of work:
Check one: ❑New Construction ❑Remodel* ❑Addition*
Check all that apply: ❑+ Framing M Mechanical ❑ Plumbing ❑ Electrical
NOTE: Anysub-contractors involved will need to submit their own signed applications.
Description of work: Remodel of Rooms 170,244 and 250
*Total cost of project - materials and labor: $ (used to calculate permit fees) # Of Buildings:
Building 1: __Units sq. ft Building 2: Units -sq. ft. Building 3: __Units _ sq. ft.
Additional Buildings:
Utility, Misc, Private Garage: sq. ft Storage: sq. ft.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Underpenalty ofperjury, l hereby certify that I have read this application and state thatthe information herein
Is correct and 1 swear that any 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. 1 agree to comply with all City regulations and State laws relating to the subject matter ofthis application and hereby authorized representatives ofthe
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 rases ofany fake statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Permit void Hart
started within 180 days. Permit void ifwark stops for 100 days.
Applicant's Name (print): Terrie Larsen Signature: Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM wi116e scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
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CITY OF
REXBURG
America's Family' Community
State of Idaho
County of Madison
I, --
Name
Rexburg
City
Building Safety Department
Submit By Emall City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
Affidavit of Legal Interest
Address
State
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
A. That I am the record owner of the property described on the attached, and I grant my permission to:
Name
Address
to submit the accompanying application pertaining to that property.
B. 1 agree to indemnify, defend and hold Rexburg City and its employees harmless from any claim or liability
resulting from any dispute as to the statements contained herein or as to the ownership of the property
which is the subject of the application.
Dated this
day of
20
Signature
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Inspection Hotline -(208)372.2344 w .rexhurg.org Permit Technician -(208)372.2341 Revised March, 2016
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CITY OF
91
n
° REXBURG
ty�
America's Family Community
Submit By Email
BUILDING APPLICATION
Mechanical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: _ Permit Type: ❑ New ❑ Remodel ❑ Addition ❑ Basement Finish
Fees Paid: ❑ Yes []No
1. Property Owner
Name:
Address:_ City: Rexburg State: Zip Code:
Phone & Type: ❑ Office ❑ Mobile 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 #3 and complete the Homeowner's Exemption page)
❑ No: I am a contractor working for the homeowner ❑ No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contractors/sub-contractors involved will need to submittheir own signed applications.
2. Mechanical Contractor
Name: Registration #: Exp.:
Address: City: _ State: Zip Code:
Phone & Type: ❑ Office ❑ Mobile Email:
Contact/Rep. Name: Phone: _ Email:
Mechanical Contractor Authorized Signature!;Date:__
3. Project Description
Address: _ -OR- Lot #: _ Block #: _ Subdivision: _
Check one: ❑ Single-family Residence ❑ Multi -family Residence ❑ Commercial
Check one: ❑ New Construction* ❑ Remodel ❑ Addition ❑ Basement Finish
Description of work:
New Commercial Work: Contracted amount: $ Calculated Fee (See Below): $ __
❑ Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,0014100,000 = ((total cost of system -10,000) x.01) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: Sq. Ft
❑ Up to 1,500 Sq. Ft. = $130 ❑ 1,501-2,500 Sq. Ft = $195 ❑ 2,501-3,500 Sq. Ft = $260 ❑ 3,501-4,500 Sq. Ft = $325
[]Over 4,500 Sq. Ft = $325+(65 x # of additional 1,000 Sq. Ft. (or portion thereof)) $
New Multi -Family Residential: ❑ Duplex= $260. ❑ Three or more units= $((130 x# of buildings)+(65 x # of units))$_
New work on any other residence and Detached Shops: = $(65 + (10 x # of HVAC fixtures)) $
Miscellaneous: ❑ Gas Pressure= $65 ❑ Furnace or A/C = $65 ❑ Water Heater= $65 ❑ Requested Inspection= $65
❑ Gas. Line =. $65,.. ❑.Fireplace/Solid .Fuel Burning Unit= .$65....❑ Technical Service= $65/hour ,-
❑ Plan Check =10% of Contracted Amount
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that 1 have read this application and state that the information herein
is correct and 1 swear that any information which may hereafter be given bymein 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 ofthis application and hereby authodzed representatives of the
City to enter upon the above-mentioned property Por inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions of the 2012
International Code in cases ofany fake statement or misrepresentation offact in the application or on the plans on which the permit or approval was based. Permit mid if not
started within 180 days. Permit void ifwork 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 B AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
RL.X17URG Submit By Email
tn
Amerimi rnmilyCommBBiry,
BUILDING APPLICATION
Electrical
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: _ _ Permit Type: ❑ New ❑ Remodel ❑ Addition ❑ Basement Finish
Fees Paid: ❑ Yes ❑ No -
1. Property Owner
Name:
Address: City: State: _ Zip Code: _
Phone & Type: ❑ Office ❑ Mobile 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 #3 and complete the Homeowner's Exemption page)
❑ No: I am a contractor working for the homeowner ❑ No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contractors/sub-contractors involved will need in submit their own signed applications.
2. Electrical Contractor
Name: Registration #: __ Exp.:
Address: City: State: Zip Code: _
Phone & Type: ❑ Office []Mobile Email:_
Contact/Rep. Name: _ Phone: Email:
electrical Contractor Authorized Signature Date:
3. Project Description
Address: _ -OR- Lot #: _ Block #: _ Subdivision: _
Check one: ❑ Single-family Residence ❑ Multi -family Residence []Commercial
Check one: ❑ New Construction* ❑ Remodel ❑ Addition ❑ Basement Finish
Description of work:
New Commercial Work: Contracted amount: $ Calculated Fee (See Below): $_
❑ Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,0014100,000 = ((total cost of system -10,000) x.01) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: Sq. Ft.
❑ Up to 1,500 Sq. Ft. = $130 ❑ 1,501-2,500 Sq. Ft = $195 ❑ 2,501-3,500 Sq. Ft = $260 ❑ 3,501-4,500 Sq. Ft = $325
❑ Over 4,500 Sq. Ft = $325+(65 x # of additional 1,000 Sq. Ft. (or portion thereof)) $
New Multi -Family Residential: ❑ Duplex= $260 []Three or more units= $((130 x # of buildings)+(65 x # of units))$
New work on any other residence and Detached Shops: _ (65 + (10 if # of branch circuits)) $
Miscellaneous: ❑ Small Works (work costing less than $200 with no change in service connections)=$1 0 (needs no inspection.
[]Central Heating/Cooling Systems= $65 ❑ Spas, Hot Tubs, and Swimming Pools= $65 ❑ Requested Inspection= $65
❑ Pumps -Water, Irrigation, Sewage (per motor) = ❑ $65 up to 25HP ❑ $95 26- 200HP ❑ $130 over 200HP
❑.Irrigation Machine.=. $65for center .pivot+.$10 per tower of drive. motor.$ .. []Technical Service = $65/hour -
❑ Temporary Amusement= $65 + $10 per ride, concession, or generator $ ❑ Plan Check =10% of Contracted Amoun
oTemporarV Construction Services ONLY= $65 f200 amp or less. One location for less than 1 ear.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Underpenalty ofperjury,thereby certify that l have read this application and state that the information herein
is correct and 1 swear that any 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 coma I agree to comply with all City regulations and State laws relating to the subject matter ofthis 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 ofany false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permitvoidif not
started within 180 days. Permit void ifwork stops for 180 days.
Applicant's Name (print): _ Signature: Date
Inspections most 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.rexhurg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
RiXBURG Submif By Email
Amedaa' rvunilyCounnunify
BUILDING APPLICATION
Plumbing
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: - Permit Type: ❑ New ❑ Remodel ❑ Addition ❑ Basement Finish
Fees Paid: ❑ Yes ❑ No
1. Property Owner
Name:
Address: City: _ State: _ Zip Code:
Phone &Type: ❑ Office ❑ Mobile 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 #3 and complete the Homeowner's Exemption page)
❑ No: I am a contractor working for the homeowner ❑ No: This property is a Multi -family Residence or Commercial Property.
NOTE: Any contractors/sub-cantactors involved vAU need to submit their own signed applications.
2. Plumbing Contractor
Name: _ Registration #: _ Exp.:
Address: City: State: Zip Code: _
Phone & Type: ❑ Office ❑ Mobile Email:
Contact/Rep. Name: _ Phone: _ Email: _
Plumbing Contractor Authorized Signature_ Date:_
3. Project Description Water Meter Quantity: Water Meter Size:
Address: _ -OR- Lot #: _ Block #: _ Subdivision:
Check one: ❑ Single-family Residence ❑ Multi -family Residence ❑ Commercial
Check one: ❑ New Construction* ❑ Remodel ❑ Addition ❑ Basement Finish
Description of work:
New Commercial Work: Contracted amount: $ Calculated Fee (See Below): $
❑ Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,0014100,000 = ((total cost of system -10,000) x.01) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
New Single -Family Residential Work: Sq. Ft.
❑ Up to 1,500 Sq. Ft. = $130 ❑ 1,501-2,500 Sq. Ft. = $195 ❑ 2,501-3,500 Sq. FG = $260 ❑ 3,501-4,500 Sq. Ft. = $325
❑ Over 4,500 Sq. Ft. = $325+(65 x # of additional 1,000 Sq. Ft. (or portion thereof)) $
New Multi -Family Residential: ❑ Duplex= $260 ❑ Three or more units= $((130 x# of buildings)+(65 x # of units))$_
❑ Gray Water Systems= $130 ❑ Lawn Sprinklers/Backflow device= $65 ❑ Multipurpose Fire Sprinkler & Domestic Water
Supply System = $65 or $4 per sprinkler head (whichever isrester
New work on any other residence and Detached Shops: = $65 for sewer and water stub connections ❑
Miscellaneous: ❑ Sewer Line = $65 ❑ Water Line = $65 ❑ Sewer and Water Line= $65 ❑Requested inspection= $65
❑ Sewer Turnaround (septic to city) = $65 --❑ Hydronic Heating= $65 +{$10 x # of manifolds/zones) -
❑ Technical Service= $65/hour ❑ Plan Check =10% of Contracted Amount
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that l have read this application and scene thatthe information herein
is correct and I swear that any information which may hereafter be given bymein 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 whit all City regulations and State laws relating to the subject matter ofthis 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 misrepresentadon offact in the application or on the plans on which the permit orapproval was based. Permit void if not
started within 180 days. Permit void 1fwork stops for 180 days.
Applicant's Name (print):
Signature:
Inspections must be called in before SAM on the day the inspection is requested. Inspection requests called in after a AM will be scheduled for the next business day.
Inspection Hotline -(208)372.2344 www.rexburg.mg Permit Technician -(208)372.2341 Revised March, 2016
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64oQ cis CITY OF
° RMURG
tti
America's Family Community
i
Building Safety Department
Submit By Email City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
BUILDING APPLICATION
Fire Alarm
For Office Use
Permit Number:
Permitapproved: ❑Yes ❑No
Fees Paid: ❑ Yes ❑ No
1. Applicant
Business Name:
Office Address: City: Rexburg
State: Idaho _Zip Code: 83460-8205
Office Phone: Contact Person:
Cell Phone: 208-681-0255
6ontr
Date: 9/1/2016--- ----
License/Registration # Expiration:
2. Location of Work to be Done
Street Address: _City:
State:_ Zip Code:
Business Name:
Contact/Rep. Name: Terrie Larsen Phone:
_13 Office ❑ Cell Phone
Email: larsent@byuj.edu
Dates for work to be done: From to
3. New Construction Contracted Amount: $ _
Calculated Fee (See Below): $
❑ Up to $10,000 = (total cost of system x.0 2) + $60 ❑ $10,001-$100,000 = ((total cost of system -10,000) x.0 1) + $260
❑ Over $100,001= ((total cost of system -100,000) x.005) + $1,160
4. Miscellaneous
❑ Plan Review = 10% of Contracted Amount
❑ Re -Inspection = $65
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
correctand I swearthat any information which may hereafterbe given byme in hearings before the Planning and Zoning Commission orthe City Council for the City ofl exhurg shall
be truthful and correct. I agree to comply with all City regulations and State laws relating to the subject matter ofthis application and hereby authorized representatives ofthe 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. Permitvoid if not
started within 180 days. Permit void if workstops for 180 days.
Applicants Name (print): Terrie Larsen
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.moburg.org Permit Technician -(208)372.2341 Revised March, 2016
�;oQ pbXBng�r9 CITY OF Building Safety Department
REXBURG Submit By Emall City of Rexburg
to 35 North 1st East
America's Family Community Rexburg, Idaho 83440
BUILDING APPLICATION
Fire Sprinkler
For Office Use -
Permit Number:
Permit approved: ❑ Yes ❑ No
Fees Paid: ❑ Yes No
1. Applicant
Business Name:
Office Address: City: Rexburg
_State: Idaho -Zip Code: 83460-8205
Office Phone: Contact Person:
Cell Phone: 208-681-0255
ontraetor Attthorise"itlaturel_ -- ----_
- --Date: 9/1/2016- -
License/Registration # Expiration:
2. Location of Work to be Done
Street Address: City:
State: Zip Code:
Business Name:
Contact/Rep. Name: Terrie Larsen Phone:
_
__D Office ❑ Cell Phone
Email: larsent@byui.edu
Dates for work to be done: From to
3. New Construction Contracted Amount: $_
Calculated Fee (See Below): $
❑ Up to $10,000 = (total cost of system x.02) + $60 ❑ $10,001-$100,000
= ((total cost of system -10,000) x .01) + $260
❑ Over $100,001 = ((total cost of system -100,000) x.00 5) + $1,160
4. Miscellaneous
❑New Construction = $1 per Sprinkler head ($2,000 max) # of heads:
❑Existing Inspection Base = $65
❑Plan Review = 10% of Contracted Amount
❑Re -Inspection = $65
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that 1 have read this application and state that the information herein
correct and 1 swear that any information which may hereafter be given bymein 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 ofthis application and hereby authorized representatives ofthe 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 plans on which the permit or approval was based. Permitvoidifnot
started within 180 days. Permit void ffwork stops for 180 days.
Applicants Name (print): Terrie Larsen Signature:
Date:
Inspections most be called in before SAM on the day the inspect an 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 Revised March, 2016
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists: _
Siding/Exterior Trim:
Other:
Inspection Hotline -(208)372.2344 w .rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
CITY OF
0 Rr!XB RG Submit By Emall
CW 117
Amencab Fomily Community
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
Subcontractor List
Excavation & Earthwork:
Concrete:
Masonry:
Roofing:
Insulation:
Drywall:
Painting:
Floor Coverings:
Plumbing:
Heating:
_
Electrical:
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists: _
Siding/Exterior Trim:
Other:
Inspection Hotline -(208)372.2344 w .rexburg.org Permit Technician -(208)372.2341 Revised March, 2016
M1;o 4 a°8s ' CITY OF Building Safety Department
a REXBURG Submit By Email City of Rexburg
CI 35 North 1St East
America's Family Community
Rexburg, Idaho 83440
BUSINESS USE SUMMARY
The following questions will help speed the review process along. Please take the time to answer all of them.
Is this business occupying an existing building? XYes ❑ No
Will the business be doing any structural/or remodeling changes to the building? )3'Yes []No
Any changes to the electrical? Zyes []No
Any changes to the plumbing? ❑YesffNo
Any changes to the mechanical system? ,D'i'es ❑ No
Is the business type changing? ❑ Yes, it will change to IXN0
Is this business changing ownership? []Yes O'go
Is the business registered with the City of Rexburg?[] Yes, License #: []No
*If No, please apply for a business license with the Customer Service Dept.
Will the business have food preparations? []Yes ONo
Will there be any cooking of foods? []Yes Wo
Will there be any deep fat frying? ❑Yes ;3'No
Will you have food disposal on site? []Yes On
Will there be sumps or floor drains in the facility? ❑ Yes oo
Will the business have any chemicals on site? []Yes 00
208-681-0255 9/1/2016
Applicants Sli6nature Phone Date
l certify that the information that l have provided above is to the best of my knowledge accurate and true.
Inspection Hotline -(208)372.2344 w .rexburg.org Permit Technician -(208)372.2341 Revised March, 2016