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HomeMy WebLinkAboutAPPLICATION - 18-00672 - 30 S College Ave - Water Line4� Qo I `Y ° Building Safety Department REXBURG BUILDING PERMIT FORM City of Rexburg 0W,„ date 2/2et7 43 0 Arnertca4FamilyComrrtunity 35 North Ist East Rexburg, Idaho 83440 BUILDING APPLICATION Miscellaneous Plumbing Work For Office Use Permit Number: El Plumbing Fees laid I. Property ©caner Name: ` Address: .e - ;Z 3 Phone: city: r lU State: - Zip Code: EmaiUnder Idaho Building Code, a homeowner is allowed to do work on l 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 Z. Plumbing Contractor Under Idaho Building code, a registered contractor m ust do the work for a Commercial Building. Business: - Address: State License #: //s Exp.: City: Phone: f State; Zip Code: Contact/Rep. Name: Email: Oil, St_ Email: Plumbing Contractor Authorized Signature: A copy ofyourstute registration/Iicertse Is required to be r is t Date: ° photo copy ofyour license. ffyou are unsure ifyour license is on file, please check with the Permit Technician by callingave done work in the (2 08) 2f 2341 provide 1 Project Description Address: -5- 'ek- i/C-- -OR- Lot #: — Block #: Subdivision: What type of Property: p Residential ❑ Commercial Cost of Job; $ Description of work:6/�`�/> �rsfv� 4. Fees: Check all that apply: 0 Gas Line = $65 ❑ Water Heater = $65 Cl Sewer Line = $65 ,19, Water Line = $6S 7, , ❑ Lawn Sprinklers/Backflow device = $65 ❑ Gray Water Systems = $130 ❑ Hydronic Heating = $65 t ($10 x # of manifolds/zones) = ❑ Miscellaneous/Requested inspection = $6S ❑ Sewer Turnaround (septic to city) = $65 Inspection fees can be bundled upon request, Re -inspect fees will be enforced if inspection requests exceed fee totals, APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, I hereby certify that I have read this application and state that the information her as correct and 1 swear that any information which may hereafter at given d to in hearings before the planning and Zoning Commission or the Qty Council for the City of Rexhu shall be truthful and correct ]agree to comply with all City regulations and state laws relating to the subject matter of this application and hereby authorised representatives r city to enter upon the above-mentioned property for inspections purposes. NOTE- The hull ding official may revoke a permit on approval issued under the provisions of the 21 International Code in cases of any false statement or misrepresentation started within 1$0 days. Permit void if work stops for 1130 days. affact In the application or on the plans an which the permit or approval was based. Permit void if nn Applicant's Name (print): Signature:.f� Date: inspection Hotline e- or(20$] 372.2344 as) be called in before SAM on the day the 4nspettion is requested. inspection requests called in after a Aryl will be scheduled for the next business da www.resburg.org