HomeMy WebLinkAboutAPPLICATION - 18-00028 - 51 K St - Water Line Replacement40a as enac4' CITY OF
e lfId V RG BUILDING PERMIT FORM 4,30
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BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 63440
For Office Use
❑ Plumbing FeeJPaid
Permit Number:
1. Property Owne
Name
Address:City: e� U StatZip Code:
Phone: Zo6-RTO-S9Lo Emad: �G'4 e"r'!wb7 Ar 00 Gi
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
[U,d,,
mbing Contractor
Idaho Building Code, a registered contractor must do the work for a Commercial Building.
ess: �.i'fi/J��iiY/8.f L�G325�V'���'I'a'pgtaatto L�i.,cense#: Exp.:
ess: �'�'Fm"�-5a3 �' City: 9B State:,-Z1p Code:'�L.
e: A/�r /35% 5�a- Email: -ireti,a/.-u ��m''�i't r'
act/Rep. Name: �� `2 Phone: Email:
bing Contractor Authorized Signature: 6 �'z Date:
y ofyour stare registraton/license is required to eonffle. if this is thefot timeyou have done work In the City ofRexung, please provide
o photo copy ofyour license. Ifyau are unsure flour license is on file, please check with the Permit Technician by calling (208) 372-2341.
rDescription
Description
�l % �9y � -OR- Lot #: _ Block #: _ Subdivision:
e of Property:"esidential ❑Commercial
b:$�.�" /' .�6-
of work: fca /N-^'t�'�-
heck all that apply:
as Line=$65 ❑ HydromcHeating=$65+($l0X#of❑Water Heater =$65 manifolds/zones)=$
❑ Sewer Line =$65 ❑ Miscellaneous/Requested inspection $65
TK Water Line = $65 ❑ Sewer Turnaround (septic to City) = $65
❑ Lawn Sprinklers/Backflow device =$65 Inspection fes can be bundled upon request Rivinspectfeeswill be
❑ Gray Water Systems =$130 enforced ifloolectier requests exceedfe rotate,
APPLICANTS SIGNATURE, CERTIFICATION ANO AUTHORIZATION: Under penalty of p njury.l hereby certify that I have read this application and suite Mat the information herein
rrectandlswear MatanyinfortnatlonwM1ich may M1ereaftam be given by mein hearings before the PUnnes and Simon Commission or Me City Council for Me City ofRuburg
shadibettuMfulandmrtttt Icame tommply with all City calmatlons andState laws reUting M the subject mr. mare application and hereby auNmlmd representatives of One
City M enter upon Me above-mentlnned property for Wpec ns mcaosex NOTE: The building official con"rooke a permit on approval Issued under the provisions of the 2012
Ince mmorul Code in cases ofany false statement or mierepve enation of Net In me applimHon or on the plans on which the permit or approval was based Permltvoidifmt
started niMin 100 days. Perml[void ilworkrtops for 180
'days.gnatureApplicants Name (print]I l m�/#ds
Date
Inspersions mu thew ed inbeforee AM once day Me Inspection is requested. Inspection reques5called inaRer SAM value, sch duuadfforrc h^ �^ n(mes 38.2341
es day.
InsPc¢ H
ion otline-(200)372.2344 www+exbuctine