HomeMy WebLinkAboutAPPLICATION - 17-00619 - 120 Elm Ave - Sewer Repair in YardC I TY OF
REXBURG
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Amenask Family Community
BUILDING PERMIT FORM 430
uprated 10/:016
BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ❑ Plumbing Fees Paid
1.Propepynar Pr
Name: /t��V
Address: /2t) F�/Yl /7 P City: P—eVJ%WLG State: Zip Code:
Phone: tis a I 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)
011 am working with the homeowner
Z. Plumbing Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: f�t�V��t "W2:E Sfl/r�-e� State License#: Exp.:
Address: 1Qrf)G .%moi City: A�462??A:d State: Zip Code:
Phone: WE) q yM10 Email:
Contact/Rep. Name:— . Phone: Email:
Plumbing Contractor Authorized Signature: I lAG Date:. % )
.I copy ofyour state registration/license is required to be on file. If this is Yhefirst tirneyou have done work in the City of Rexburg, please provide
n photocopy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
. Project Description
Address: -OR- Lot #: _ Block #: _ Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
-1. Fees: Check all that apply:
❑ Gas Line = $65 ❑ Hydronic Heating = $65 + ($10 x # of
❑ Water Heater = $65 manifolds/zones) = $
7svSewer Line = $65 ❑ 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.
APPLICANT'S 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 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 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 offact in the application or on the plans on which the permit or approval was based. Permitvoidifnot
started within 180 days. Permit void if work stops for 180 days.
Applicant's Name (print,, Signaturere V Date: 1�? -7 -7
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.rexburg.org Permit Technician - (208) 372.2341