HomeMy WebLinkAboutAPPLICATION - 17-00685 - 885 N 12th W - SFR Mechanical OnlyCITY OF
REXBURG
Americas Family Community
BUILDING PERMIT FORM 430
updaW 10/2017
BUILDING APPLICATION
Miscellaneous Phtntbkg Work
MPe-l.r A%1 tat_QJ
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use /
.Permit Number: — coIO �� ❑ Plumbing Fees Paid
1. Property Owner
Name: es& _ �y
Address: At/ City: 4tzState: Zip Code:
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 Idaho Building Code,, a registered contractor must do the work for a Commercial Building.
Business: fe/ruiJ S �� State Lic rise #: �33 Y ���'� Exp.:
Address: 77_ 7 e' ,�.� City: iState:,lle�5) Zip z/ ode: 9
O
Phone: — O Email: U /Q//r�%li41' P G(
Contact/Rep. Name: Keh Phone: / Imail:
Plumbing Contractor Authorized Signature: sC ��f� l,"e Date:
A copy ofyourstate registration/license is required to be ori file. If this is [he%irst ti you 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 Descriptions
Address: gg✓` N a 5�% 1AP -OR- Lot #: Block #: Subdivision:
What type oferty:p Residential [3 Commercial
Cost of job: $Pro Aa
Description of work:�6i/IeA* j' -d (2�1�/G�i9tG�
4. Fees: Check all that apply:
Gas Line = $65 ❑ Hydronic Heating= $65 + ($10 x # of
❑ Water Heater = $65 manifolds/zones) = $
❑ Sewer Line = $65 ❑ Miscellaneous/Requested inspection = $65
❑ Water Line = $65 ❑ Sewer Turnaround (septic to city) = $65
❑ Lawn Sprinklers/Backflow device =$65 Inspectionfeescan bebundled 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 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 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 of the 2012
International Code in cases of any false statementor misrepresentatl n of fact in the application or on the plans on which a permit or approval was based. Permit void if not
started within 180 days. Permit void ifwor sto for lao days.
kl
Applicant's Name (print): h Signature: Date:
Inspections must be called in before a AM on the day the inspection is requested. Inspection requests called in after 8 M will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburgarg Permit Technician - (208) 372.2341