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HomeMy WebLinkAboutAPPLICATION - 17-00707 - 111 K St - Gas LineoY gBR9 V,qC CITY n P Building Safety Department p BUILDING PERMIT FORM 4,3 � City of Rexburg Cay Updated 1012016 35 North 1St East America's Family C©mrnuuiiy Rexburg, Idaho 83440 BUILDING APPLICATION Miscellaneous Plumbing Work For O4f.c 'l sc Permit Number; ' C] Plui ibin,, Pees Paid P -'� 1, i'rt� ert r OwnerName• s., �/4AVU Sc�A; Address: 6i ! _ iC Sz{c City; 6 c State: -r-= Zip Code, Phone: 2-T Z.z-�- t Z f$g 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 #h and complete the Homeowner's Exemption) ❑ No, I am working with the homeowner 2. Pluin ping Contractor Under Idaho Building Code, a registered contractor must do the work for a Commercial Building, Business: e1. State License #: 14t - C - / 1'l e Ex V � dyo Address 0 w p''' �` 1. vu -f Phone a City: State:, Zip Code:!'34i�/S' . - Email; Contact/Rep. Name: U C hone: -&a Email: pNe e _ i PIuM, bIng Got>tratit�?r i pt t Date: l/ % cvpy ctry�ourstore r gistration/license is required to be on fila If this is thefrst imeyau have ne worTrin the City ofRexburg, please provide a photo copy ofyour license, If you are unsure if your license is on file, please check i0th the Permit Technician by calling (208) 372-2341. 3, Project Description Address: iii K 5 -0111_ Lot #: Block #; _ Subdivision: What type of Property: ❑ Residential ❑ Commercial Cost of job: $ Description of work: -,_ --/.I eti Cs cr- 4. Fees: Check all that apply: Gas Line = $65 ❑ Hydronic Heating= $65 + ($lox # 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 Ins�ec6on fees can be bundled upon request Re-inspectfees Mill be ❑ Gray Water Systems = $130 enforced ifinspection requests exceed fee totals. APFLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty ofperjury, I hereby certify that I 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 he truthful and correct, I agree to comply with all City regulations and State laws relating to the subiect 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 cn 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 pians on which the permit or approval was based. Permlt void if not started within 180 days. Permit void ff warkstops for 180 days. Applicant's Name (print):e- 'ALeh Signature:` r Date: 7 Inspections must be called in before 8 AM an the day the inspection is requested. Inspection requests called in after SAM will be scheduled for the next business day. inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341