HomeMy WebLinkAboutAPPLICATION PLUMBING - 17-00585 - 906 W 7th S - SewercwVARVIR� Building Safety Department
is CITY OF
-i City of Rexburg
REXBURG BUILDING PERMIT FORM 430
Updated 10/2016 35 North 1St East
Americas Family Community Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Plumbing Work
For Office Use
Permit Number: ❑ Plumbing Fees Paid
1. Property Owner /1
Name: A( ` r
Address: go City: 1 14 State:_ Zip Code: t {
Phone: 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 IdahoBuilding Code, a registered contractor must do the work for a Commercial Building.
Business: All ffLwf P4 M 11kr State License #: M`4-- Exp.. MOD
Address: Zt _ City: State: i Zi Code:
Phone: ?_r 7*beo?.�I�,,
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Contact/Rep. Name: ` Email:
Plumbing Contractor Authorized Signatur Date: (&J i 7
A copy ofyour state registration/license is reque fast ti ou have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure iflease the with the Pemiit Technician by calling (208) 372 2341,
3. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
4. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating= $65 + ($10 x # of
❑ Water Heater = $65 manifolds/zones) = $
Sewer Line = $65 ,— New ❑ 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.
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APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHOIfION: Under penalty of perjury, I hereby certify that I 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 r of this application and hereby authorized representatives of the
City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official 1 oke 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 aro a ns on which the pe approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print): C SigZ
Date: Z�
Inspections must be called in before 8 AM on the day the inspection is reques req call d in after 8 will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341