HomeMy WebLinkAboutAPPLICATION - 18-00430 - 525 S Center St - BYUI - Benson RemodelCITY OF
REXBURG
Ow -
America's Family Community
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
COMMERCIAL REMODEL/TENANT IMPROVEMENT APPLICATION CHECKLIST
The following items should be completed before you submit your building permit application.
*Reasonable accommodations will be made upon request.
Submit the Following Documents:
❑ 3 sets of building plans - stamped by a licensed professional.
Include the following as applicable
❑ Foundation Plan, FloorJoist Layout, Floor Plan, Roof Layout, Truss Details, Sectional Views, Front, Back, and Side
Elevations, Mechanical Layout, Stair Details, and any details required to illustrate special construction.
❑ Electrical panel layout and calculations included with building plans.
❑ Exterior Lighting Plan including photometric layout.
❑ Structural Calculations (if applicable) - stamped by a licensed Engineer
❑ Digital Plans (PDF Format - can be submitted by USB, CD, or Dropbox)
❑ **Copies of any Contractors' State License if not on file already.
Complete the Following Forms
❑ Permit Policies Acknowledgment signed
❑ Building Permit Application signed by a registered General Contractor
❑ Mechanical Permit Application signed by a registered Mechanical Contractor
❑ Electrical Permit Application signed by a licensed Electrical Contractor
❑ Plumbing Permit Application signed by a licensed Plumbing Contractor
❑ Fire Alarm Permit Application (if applicable) signed by a registered professional
❑ Fire Sprinkler Permit Application (if applicable) signed by a registered professional
❑ Subcontractor list filled out
❑ Affidavit of Legal Interest signed by owner
❑ Notifications Distribution List
❑ Business Use Summary Completed
Subdivisions: If you plan to build in a subdivision please check the Rexburg Development Code for
any requirements such as property setbacks, architecture board approval, etc.
This information is available at httn://rexburg org/page5idevelopmPrit-code.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341
Revised 10/2016
OF RBX B URC
y CITY OF Building Safety Department
' REXBURG City of Rexburg
America's Family Community 35 North 1St East
Rexburg, Idaho 83440
PERMIT POLICIES ACKNOWLEDGMENT
The City of Rexburg Building Safety Department is determined to provide excellent customer service. In an effort to help you
understand the City of Rexburg Permit Policies, listed below are several policies which you are required to know prior to
proceeding with your project.
Any construction within the City of Rexburg which requires a permit shall not begin until an approved permit is
obtained. If you do not have a Pink Building Permit signed by the Building Inspector, then you do not have an
approved permit.
o Building without the pink building permit signed by the Building Inspector will result in double fees to be
assessed and the project to be red tagged. If your project is red tagged, halting all construction, only a City
Initials Official may remove the red tag. If the red tag g is removed by anyone but a City Official, citations maybe
issued.
No building may be occupied without receiving a signed Certificate of Occupancy.
o If a building is occupied without receiving a signed Certificate of Occupancy, citations may be issued and the
occupants may be evicted.
Initials
Scheduling inspections is the responsibility of the applicant and their contractor. Inspections need to be called
into the hotline and not to the inspector. Inspections called in later than 8 AM will be scheduled for the following
business day.
o If an inspection is not done, the inspector may require any measures to be taken to allow him to correctly
'f perform the inspection. (Example: If the electrical rough in inspection is not done and the sheetrock has been
Initials put up, the inspector may require the sheetrock to be removed in order to perform the electrical rough in
inspection.)
Construction on any project can begin ONLY when you have received a Pink Building Permit from the Building
Department. Occupancy of any structure can begin ONLY when you have received an official Certificate of
Occupancy from the Building Department. These documents must be signed by the appropriate authorities from
the City of Rexburg. Any approvals can be verified by calling (208) 372-2341.
o Even if you hear from an inspector that'you're good to go', ultimately if you do not have a Building Permit or
Certificate of Occupancy, the above policies will be enforced.
Initials
It is your responsibility to inform anyone on your project of the above policies. All sub -contractors will be held
to this standard with no exceptions.
o The above policies will be enforced to all, regardless if this information is passed on to them or not.
Initials
Applicant's Name (print): J e wil i, La✓2 /1 Signature: —_tJAAA1t
Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341
Revised 10/2016
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r� REXBURG BUILDING PERMIT FORM 2 1 City of Rexburg
``7►► Cw Updated l0/2016 35 North 1St East
America's Family Community
Rexburg, Idaho 83440
BUILDING APPLICATION
Commercial Remodel
For Office Use
Permit Number:
Application Fee: ❑ $100
1. Property Owner
Name: 510- 1&, "
Address: 15�S' S C r Sh►^tLf- City: 12,',c6!4 State: —L2_Zip Code: 53,Vivo-5zo
Phone: �ZD�� yglo- �(�(Email: lavice,,t
2. Applicant
Name: Role: (Owner, Tenant, Contractor, etc.)
Address: �iZS. � 60-HfPi Sbn!e1, City: r State: IPS Zip Code:83t1�(i-82Gb'
Phone: �7� tf�(. 7 z Email: QVSPn-F /a fog ui e��A
Contact/Rep. Name: T✓1 �►���,
3. General Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Name: PAY U - I da lkn Registration #: Exp.:
p"
City: State: Zip Code:
Phone: Email:
Contact/Rep. Name: Phone: Email:
General Contractor Authorized Signature: Date:
A copy ofyour state registration/license is required to be on file. If this is the first time you have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on file, please check with the Permit Technician by calling (208) 372-2341.
4. Project Description ` FvenSo►� �wjdrn� 06-ov"4 Z331 7,3551 7,3$, 2qa4 7-q2-
Address:
-q2Address: 505 S. C�nfiG� Si'�,rr
Description of Work: revlod—l.l (f
Project Description:
• Total cost of project - materials and labor: $ 3 3 r
• Check all that apply:
❑ Mechanica�ost $_10S7-70 ❑ Electrical: Cost $ (2� ?z.7�i ❑ Plumbing: Cost $ O
❑ Fire Alarm: Cost $ U)t) ❑ Fire Sprinkler: Cost $ Q
Note: Any contractors involved will need to fill out their respective application.
• Change of Occupancy? X No ❑ Yes: New occupancy:
Building Permit fees for commercial construction are charged based on square footage and the City's estimated valuation. The
application fee applies toward the fee total. For details on how fees are calculated, contact the Building Department. There will also be a
plan review fee totaling 10% of the building permit fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, 1 hereby certify that I have read this application and state that the information herein
is correct and 1 swear that any information which may hereafter be given by mein 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.
Applicant's Name (print): 5yo- jelalu Signature: ly Avner_ Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business da
Inspection Hotline – (208) 372.2344 www.rexburg.org y.
Permit Technician – (208) 372.2341
OF REX D URC
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7 Building Safety Department
` -
Ur� REXBURG BUILDING PERMIT FORM 210 City of Rexburg
cy, Updated 10/2016 35 North 1St East
America; Family Community
Rexburg, Idaho 83440
BUILDING APPLICATION
Commercial Mechanical
For Office use
Permit Number:
Mechanical Fees Paid 0
1. Property Owner
Name: 6Y U- {duke
Address:_ 5Z5- S,2LAU Cdv fe. 5 I- City; State:
11L_ Zip Code: _83t/1„n
Phone: 47AS qq(- Z&(4-2,
Email: _ to✓SCn { 0 6,u edct
2. Mechanical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: RAY 0 - 1 d4k o State License #: 0(241;,7 - -I ncius ��
Address: SZ 5 0,,wl i p"
�fi'1°��� City: a(7u. State: I D Zip Code:
Phone: Email:
Contact/Rep. Name: Sam VYl { ,/,r, &G Phone:5 (p - 7,510 Email: rnef✓i ckC
Mechanical Contractor Authorized Signature:
Date: -.7- -/
A copy ofyour state registration/license is required to be on file. If t . is the first time you have done work in the City of Rexburg, please provide
a photo copy ofyour license. Ifyou are unsure ifyour license is on fi e, please check with the Permit Technician by calling (208) 372-2341.
3. Project Description
Address:Mian, DcA,; di K!E , 2 31 -7,35,73$; V40, V1
Description of work: 8_ 14,.`4.;CcJ
0 Project Cost: $ 10 S7. cl o
• Fees for commercial projects are charged by cost.
o First $10,000 = 296 + $60. From $10,000 to $100, 000 = 1% + $260. Above $100, 000 =.5%, +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first $10,000 and 1916 of the remaining $5, 000 = $260 + $50 = $310 total fee
• There will 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. 1 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.
Applicant's Name (print): �9 i — 1 41tD —Signature: -Date: � Grc(,►� 7, / 7-16
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org
Permit Technician - (208) 372.2341
OF tttiX B L'aC
Y fp 9y C I T Y o f Building Safety Department
-
f� REXBURG BUILDING PERMIT FORM14�1 City of Rexburg
(�+ Updated 10/2016 35 North 1St East
America's Family Community
Rexburg, Idaho 83440
BUILDING APPLICATION
Commercial Electrical
For Office Use
Permit Number:
Electrical Fees Paid ❑
1. Property Owner
Name: Idaho
Address: 5'25S. (,ente,- 5P^e-r�p City:,moi., State:
Phone: �) Coq (� 7 („L, —Q—_ Zip Code:
Email: _ L-Lt✓�Gn LD htiU.i edu
2. Electrical Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Buildin
a.
Business: 5�`f U- d"o State License #: ELg -I -I(?, h In X�'"�
Address: 2! S. CGv> Ff si{,rej, p"
Phone: City: - ` State: _( D Zip Code: h 3 W( y
Email:
Contact/Rep. Name: StC✓'i✓ Vyi j�L Pho e: - U
Email•�v(Ces � bu I.t i . CG��I.•
I
Electrical Contractor Authorized Signature:
o g � 9 � Date:
A co
py fyour state re istration license is re uired to be on He. If this is the first time you have done work in the City of Rexburg, please provide
a photocopy 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: R,einsc,, �I�� i irc Z 3 2,35,V36, Z -W t 2t(Z
Description of work: Gl mc,�
1:1(o Project Cost: $ _ Co J`b3. 7 s n"N
• Fees for commercial projects are charged by cost.
0 First $10,000 = 2916 + $60. From $10,000 to $100,000 = 19/0 + $260. Above $100, 000 = .s% +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first$10,000 and 1916 of the remaining $5,000 = $260 + $s0 = $310_ totalFee
• There will also be a plan reviewfee totaling 10910 of the above fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that 1 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.
Applicant's Name (print):. Y L) - 1 d a dI a Signature: _Ui� Date: 7- l 7— /F,5
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org
Permit Technician - (208) 372.2341
of RExouR�:
CITY o F
' Building Safety Department
a n�
Tf� RExBuRG BUILDING PERMIT FORM 230 City of Rexburg
01V Updated l0/2016
,•' America's Family Community 35 North 1St East
Rexburg, Idaho 83440
BUILDING APPLICATION
Commercial Plumbing
For Office Use
Permit Number:
1. Property Owner
Name:
Address: _.✓i ?_ S on }G✓ Sryp City:
Phone: I -fa► (�?
Plumbing Fees Paid ❑
State: �_ Zip Code: _ 53c((,n
Email: ,-�
2. Plumbing Contractor
Under Idaho Building Code, a registered contractor must do the work for a Commercial Building.
Business: State License #:
Address: Exp.: —
City:
Phone: State: Zip Code:
Email:
Contact/Rep. Name Phone: Email:
Plumbing Contractor Authorized Signature:
A copy ofyour state registration/license is required to be on file. If this is the first time 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 Description
Address:
Description of work:
❑ Project Cost: $ IV
• Fees for commercial projects are charged by cost.
0 First $10,000 = 2% +$60. From $10,000 to $100,000=1% +$260. Above $100,000 = .5% +$1,160. i.e. Work costing
$15,000 will be charged $260 for the first$10,000 and 1% of the remaining $5,000 = $260 + $50 =L310 total ee
There will also be a plan review fee totaling 10% of the above fee.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, 1 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.
Applicant's Name (print): R Y IZ (6 4 (ny Signature: :UL1114 Date:
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org
Permit Technician - (208) 372.2341
For Office Use
Permit Number:
C I TY OF
REXBURG
America's Family Community
BUILDING PERMIT FORMw
Updated 10/2016
Building Safety Department
City of Rexburg
35 North 1St East
Rexburg, Idaho 83440
BUILDING APPLICATION
Fire Alarm
1. Property Owner
Name: 13`f U - I d a kc:)
Address: S7, S S . ��I�(-�i Shrr� City:
Phone: _ Ll 9 ( - 2 (0 2
2. Contractor
Fire Alarm Fees Paid ❑
9�%6,1.- State: 112 Zip Code: 3(1(o p
Email: (i ycen-brQ
Business: BY U - - d.c, State License #:
Address: _!, ZS S . v.rr,�,� SExp.:
City: _-_—( St t IIJ
Phone:
IAS ae. Zip Code: V3y(cc
Email:
Contact/Rep. Name: -(k"w&5 T4?OV:e., Phone: qcl (a - 30 Email: rn Oore"� u i; edu
✓rn" it i� 411G-3US(o SiIbC•� @ c�ui•� u
Contractor Authorized Signature: fLt Date: k (' !
A copy ofyour state registration/license is re ire d to be on file. If this is the first timeyou 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:. Rfr, e��,., _6, J3 3 2 35- 1 23bt 7.-Y0I 214 2
Description of work: �(e—y2,°
❑ Fire Alarm System Cost: $ D
Fees for fire alarm systems are charge by cost,
0 First $10,000=2% +$60. From $10,000 to $100,000=1% +$260. Above $100,000 = .5% +$1,160, i.e. Work costing
$15,000 will be charged $260 for the first $10,000 and 1% of the remaining $5,000 = $260 + $50 = $310, total fee
There will 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
correct and 1 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.
Applicant's Name (print): 9'Y Signature:
Date: %
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM
Inspection Hotline - (208) 372.2344 will be scheduled for the next business day.
www.rexburg.org
Permit Technician - (208) 372.2341
OF pEX B URC
CITY o E Building Safety Department
REXBIURG BUILDING PERMITdFOeRoM 4,02 City of Rexburg
America' Family Community 35 North 1St East
Rexburg, Idaho 83440
BUILDING APPLICATION
Fire Sprinkler
For Office Use
Permit Number:
Fire Sprinkler Fees Paid ❑
1. Property Owner
Name: g`(V - Idaho
Address: 5 • CPn,k-� -f1,Ce1- City:,Ia(State: /D Zip Code: o3y�
Phone: Ema,�il:
2. Contractor
Business: State License #:
Address: ity:
Phone:
Email:
Contact/Rep. Name: Phone:
Exp.:
State: Zip Code:
Email:
Contractor Authorized Signature:
Date:
A copy ofyour state registration/license is required to be on file, if this is the first timeyou 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:
Description of work:
Number of Heads:
❑ Fire Sprinkler System Cost: $ Q
• Fees for fire alarm systems are charge by cost.
o First $10,000=2910 + $60. From $10,000 to $100,000 = 110 +$260. Above $100,000=.5910 +$1,160, i.e. Work costing
$15,000 will be charged $260 for the first $10,000 and 1% of the remaining $5,000 = $260 + $50 = $310 total fee
There will 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
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 1 agree to comply with all City regulations and State laws relating
for inspections purposes. NOTE: to the subject matter of this application and hereby authorized representatives of the City
to enter upon the above-mentioned property pThe 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.
Applicant's Name (print): R Y U - 1 d!c (1 0 Signature:-iLt,1G[ rmn
Date: 7-17-/?)
Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day.
Inspection Hotline - (208) 372.2344 www.rexburg.org
Permit Technician - (208) 372.2341
o� Rtx v URS,
U� a� CITY OF _ Building Safety Department
REXBURG City of Rexburg
`y'
Americai Family Community 35 North 1St East
Rexburg, Idaho 83440
SUBCONTRACTOR LIST
Excavation & Earthwork: lj A.
Concrete:
Masonry: Fzi() - kC(w1,,
Roofing: NP,
Insulation: 5\f I) - l ctoavo
Drywall: gYV- 1 ctc,l-10
Painting: 9`LU - let4ttl
Floor Coverings: S i U - I C(a h -v
Plumbing: NW -
Heating: _1� \( U - I c( &!moo
Electrical: 91'( U - l Ae k.
Special Construction
(Manufacturer or Supplier)
Roof Trusses:
Floor/Ceiling Joists:
Siding/Exterior Trim: —
Other:
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341
Revised 10/2016
O4 pEX 0 URS,
�4 1p CT TY OF Building Safety Department
U � O
REXBURG City of Rexburg
AmericakFamily Community 35 North 1St East
ED
Rexburg, Idaho 83440
Affidavit of Legal Interest
State of Idaho
County of Madison
I,
Name
City
Being first duly sworn upon oath, depose and say:
(If Applicant is also Owner of Record, skip to B)
Address
State
A. That I am the record owner of the property described on the attached, and I grant my permission to:
Name
Address
to submit the accompanying application pertaining to that property.
B. I agree to indemnify, defend and hold Rexburg City and its employees harmless from any claim or liability
resulting from any dispute as to the statements contained herein or as to the ownership of the property
which is the subject of the application.
Dated this
day of
Signature
W
Subscribed and sworn to before me the day and year first above written.
Notary Public of Idaho
Residing at:
My commission expires:
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341
Revised 10, 2016
of REx o uR�
.o CITY OF Building Safety Department
7�
REXB RG City of Rexburg
OW35 North 1St East
America's Family Community
Rexburg, Idaho 83440
DISTRIBUTION LIST
Please provide the names and emails of anyone who should begetting automated updates for this project:
Review Notes
Name: itV✓I{, (.,G rg"-)
Name:
Name:
Name:
Name:
Inspection Tickets
Name:-,VpLfi ren
Name: $XM 4 (Dun 0(P/
Name:
Name:
Name:
Inspection Hotline - (208) 372.2344 www.rexburg.org
Email:—
1 a rs r -b 010. ed�
Email:
Email:
Email:
Email:
Email:
Ay_ .-7 , j :ed,
Email: RFf�I
_ 2�� _ kenhocltj d oG5
Email:
ebuiIdt.,- net -
Email:
Email:
Permit Technician - (208) 372.2341 Revised 10/2016
C'4 }itiXB URS:
ra C I TY OF Building Safety Department
REXBURG City of Rexburg
Americas FaCmiillyCommunity 35 North 1St East
Rexburg, Idaho 83440
BUSINESS USE SUMMARY
The following questions will help speed the review process along. Please take the time to answer all of them.
Is this business occupying an existing building?
.KYes
❑ No
Will the business be doing any structural/or remodeling changes to the building?
tvyes
❑ No
Any changes to the electrical?
'Yes
❑ No
Any changes to the plumbing?
❑ Yes
�(No
Any changes to the mechanical system?
'Yes
❑ No
Is the business type changing? ❑ Yes, it will change to
VNo
Is this business changing ownership?
❑ Yes
"o
Is the business registered with the City of Rexburg? ❑ Yes, License #:
❑ No
*If No, please apply for a business license with the Customer Service Dept.
Will the business have food preparations?
❑ Yes
VNo
Will there be any cooking of foods?
❑ Yes
VNo
Will there be any deep fat frying?
❑ Yes
1 rNo
Will you have food disposal on site?
❑ Yes
tXNo
Will there be sumps or floor drains in the facility?
❑ Yes
VN0
Will the business have any chemicals on site?
❑ Yes
IXN0
��al:t-' A'�— yl G - 2.1,(" z 7-17 - l?>
Applicants Signature Phone Date
I certify that the information that I have provided above is to the best of my knowledge accurate and true.
Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician -208 372.2341
( ) Revised March, 2016