HomeMy WebLinkAboutAPPLICATION PLUMBING -17-00248 - 875 S 5th W - 4-plex RelocationCITY OF
MX -BURG
America's Family Community
BUILDING PERMIT FORM 331
Updated 10/2014
BUILDING APPLICATION
Remodel Plumbing
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
Fol- Office Use
Permit Number: 0 Plumbing Fee Paid
1. Prop(0 vt er
Name: ( 1i1) 1
Address: City: State: Zip Code:
Phone: M 0 1 2C 3i3 - L462-7- TO M
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2. I�.�trt�Tl`(:ontracto (�
Business: MIL f lV l l'L1L I K I/l x I� State License #: �9 Exp.: -7 N 112b b
Address: L41 CC Is City: u rcl State: Zip Code: �'?>44D_
Phone: (' �� -1 E rYUICQe 60W,1 1t,' re Dft IT IIC CQY
Contact/Rep. Name: k� hone: L Email:
Plumbing Contractor Authorized Signature: Date:
A copy ofyour state registration/license is require be on fil this is i e first eyou have done work in the City of Rexburg, please provide
a photo copy ofyour license. IJ},ou are unsure ifyo it license is on file, ple se check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address: r C;,111 tv f1, 12+ )3, 1�
Description of work: 11
Remodel Cost: sq. ft.
Fees for remodels are charge by cost:•
( gn 6- o First $10,000 = 2 % -$60. From $10,000 to $100,000 =1 % + $260. Above $100,000 =.5% +$1,160. i.e. Work costing
W r pJ UW U 5,000 will be charged $260 for the first $10,000 and 1 % of the remaining $5,000 = $260 + $50 = $310 total fee
T IherAvill also be a plan review fee totaling 10% of the above fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, 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 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 statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days. 14111
Applicant's Name (print)
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in
Inspection Hotline- (208) 372.2344 www.i-exburg.org
ate:
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8 AM will be scheduled for the next business day.
Permit Technician - (208) 372.2341