HomeMy WebLinkAboutAPPLICATION PLUMBING - 16-00703 - 255 W 2nd N - 4 Plex 1Vy0 4apR�J'� T� CITY OF
"� REXBURG BUILDING PERMIT FORM t 23O
W t,aate 10/2016
America'¢ Family Community
BUILDING APPLICATION
Commercial Plumbing
Building Safety Department
City of Rexburg
35 North 11t East
Rexburg, Idaho 83440
For Office Use
Permit Number: Plumbing Fees Paid ❑
1. Property Owner
Name: Va.u- ni
Address: a -SS w. J AA City: &Ao State: TJ Code: g341W
Phone: A a-0fr--Qd-V1`10 Email:
2. Plumbing Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building,
Business: (cn ons . e Ivmb� n6, State License #: _ /4509 Exp.: is 31-111
Address: D/Itz" ♦�6 City: I`ybvr7 State: Joh( Zip Code: &3yyr
Phone: i17-�6a Email:
Contact/Rep. Name: Phone:
�. //k /7-/ Email:
Plumbing Contractor Authorized Signature: �% ++A t;yDate: /7
A copy ofyour state registration/license is require to be e on file. If this is he first time you have done work in the City of Rexburg, please provide
a photocopy 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:
Description of work: -frim Bpay, S;n�� i k cl cn 5 r\tty 7U� 0 -YJ vel trW-,Kf
❑ Project Cost: $
• Fees for commercial projects are charged by cost:
o First$10,000 = 2%+ $60. From $10,000 to $100,000 = 1% + $260. Above $100,000 =.595 +$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
• There will also be a plan review fee totaling 10% of the above fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that l 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 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. Permit void if not
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): JCr6M��{ Signature: / eXti Date: / �7
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.