HomeMy WebLinkAboutAPPLICATION - 17-00415 - 160 W 5th S - Plumbing RennovationCITY OF
REXBURG
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America's Family Community
BUILDING PERMIT FORM 23�
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BUILDING APPLICATION
Commercial Plumbing
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: Plumbing Fees Paid ❑
1. Proper( Owner
Name: '°�Q ,C,f �on,, N1t
Address:Q, r T'\ City: Q ulI-q State:�, o� Zip Code: Qi3�Nl�
Phone: a.0$ ' 3 B '11-N Emai .
2. Plumbing Contractor
Under Idaho B ildin�jCod , a registered contractor must do the work for aCommercial Building. p
Business: C Y� nr r\l� State License #: (MS;% Exp.:
Address: 165H City: 1 6��Jls Stat IZipCode: VSH01
Phone: Email: ctbl%C0�Ivv NInN IsWNO CO'\
Contact/Rep. Name: c 0 Phone: Email: T
Plumbing Contractor Authorized Signature: 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 file, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: �6 (J 1 1]1 11 II I
Description of work: oV-n1 cab �ed�2f` I. 5 1 C Oxhy 460 <010
❑ Project Cost: $ 1 1.601
• Fees far commercial projects are charged by cost:
0 First $10,000=2%+$60. From $10,000 to$100,000=1%6+$260. Above $100,000 =.5% +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first $10,000 and 1 % of the remaining $5,000 = $260 + $50 = $310 total le
• There will also be a plan review fee totaling 10% of the above fee.
APPLICANTS SIGNATURE, CERTIFICATION AND AUTHORIZATION; Under penalty ofperjury, I hereby 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 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 of any false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not -
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): C�,A� 4'taMU 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 he scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341