HomeMy WebLinkAboutAPPLICATION - 18-00453 - 154 S 3rd W - Plumbing Onlyro
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J o '•�� C IT Y OF
REXBURG
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Apnerkai Family Community
BUILDING PERMIT FORM 430
updated 2/2017
BUILDING APPLICATION
Miscellaneous Plumbing Work
Building Safety Department
City of Rexburg
35 North 1st East
Rexburg, Idaho 83440
For Office Use
Permit Number: ' Q Q s� ❑ Plumbing Fees Paid
1. Property Ownerli"rL���> 7 5 p /t
Name: l� jJ��/ 16 g5WO
Address: ! %-f'`� City: 6 State: Zip Code:
Phone: gD —35 ' ✓ 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 section 4 of this application and complete the Homeowner's Exemption page as well)
❑ No, I am working with the homeowner
2. Plumbing Contractor
Under Idaho Building Code, a registered/kcontractor must do the worfor a Commercial Building.
Business: TO ^L14 pL U /°Ilii N 6 State License #: I I hi `• - 12 55Exp.:
Address: City: State: Zip Code:
Phone: Email:
Contact/Rep. Name:Phone: Email:
Plumbing Contractor Authorized Signature: Date:
A copy ofyour state registration/license is require4lo n file. 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 Descri�1tio
Address: I S - 3 AD w- -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
XWater Line = $65 ❑ Sewer Turnaround (septic to city) = $65
❑ Lawn Sprinklers/Backflow device = $65
Inspection fees can be bundled upon request Re-inspectfees will be
Cl Gray Water Systems = $130 enforced if inspection requests exceed fee totals.
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that l have read this application and state that the information herein
is correct and I 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 ofthis application and hereby authorized representatives ofthe
City to enter upon the above-mentioned property for inspections purposes.NOTE: The building official may revoke a permit o pproval issued under the in of the 2012
International Code in cases ofany false statement or misrepresentation of fact in the application or on the plan on whicht permit or approval was based. Permit void if not
started within 180 days. Permit void if work stops for 180 days. i
Applicant's Name (print):! C LI�S�✓ Signature: u 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