HomeMy WebLinkAboutAPPLICATION - 18-00201 - 275 N 2nd W - Water Linea Tg C 1 TY OF Building Safety Department
RDWRG BUILDING PERMIT FORM 430 City of Rexburg
°°°'"°'° 3016 35 North ht East
Alnrosin Eamib rani nan;ry
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Plumbing Work
For Office Use
Permit Number: 19-Tozo I Plumbing Fees Paid
1. Property weer II
Name: �IA V�'✓i.
Address: 575 S City: State: 370 Zip Code: :
Phone: Email: Ir
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?
XYeS (Skip to #4 and complete the Homeowner's Exemption)
❑ No, I am workina with the homeowner
2. Plumbing Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: State License#: ESP.;
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
Plumbing Contractor Authorized Signature: Date:
-
A copy ofyour state registration/license is required to be on file. If this is the ffrsttimeyuu 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 Description
Address: -OR- Lot #:_ Block #:_Subdivision:
What type of Property: ❑ Residential ❑ Commercial
Cost of job: $
Description of work:
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 Inspernonfen, can he bundled upon request Re-inspectfees will be
❑ Gray Water Systems =$130 enforced ifinspection requesuexceedfee tntak
APPLICANT'S SIGNATnR& CERTIFICATION AND AUTHORIZATION: Undwpe,ultyof1wiwy,Iherebyconly in. l cave reatl Nis application and stateNat Ne Information herein
is csorrvtt nd Iovearthe,.,lnformamsn which may hereafter be given by in, in hearings beforethe Planning and Zoning Commission or the City Council for the City of Randburg
shall be truthful and correct 1 agree to complywith all City regulations and Spare laws relating to the subject matter of this application and hereby authorized represenetives ofthe
Cary to enter upon fee above-mentlonetl property forimpeetlons purposes. NOTE: TM1ebuilding oR<ial may revoke a permiton approval issued untlertce provisions of the 2012
International Code in cases ofany false statement or mistepresenatation of fact in the applanation or on one plans on which the permit or approval was based. Permirvaldifnot
stroxiwithin100days. Pefmitioud ifworkstps for 180 drys.
Applicants Namerint : oy3
(P ) Signature: t Date: h u% 2! /P
Inspectiam must be called m before SAM on Ne day the inspection is requested.Inspection requests ailed In after 8 AM wEl be scheduled for the next business day.
lospettion Hotline -(208) 372.2344 www.rmbmg.org Pettit Technician- (208) 372.2341