HomeMy WebLinkAboutAPPLICATION - 19-00012 -Avonlea Apt - Washing MachinesOQ RTABU 0
Ua a� CITY o F Building Safety Department
7
" RE.XBURG BUILDING PERMIT FORM 43 0 City of Rexburg
cy, Updated 2/2017
Ameri35 North 1St East
'•<,, � ui's Family Community
Rexburg, Idaho 83440
BUILDING APPLICATION
Miscellaneous Plumbing Work
For Office Use
Permit Number: - bub 1
❑ Plumbing Fees Paid
1. Property Owner
Name: I I, GCT
r
Address: —_ —...i 1 �i
Phone: V 0-i <_, c c m . _ _ C State: Zip Code: Cit"
I jc� Email•
Under Idaho Building Code, a homeowner is alloiveAd 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 contractor must do the work for a Commercial Building.
Business: FItii l t 1 0
1�� P f j�G State License #: Q 2Z 6 C1
Address: / 1 �,<) _Exp.:
�� City: _aEvlwut v"1 State: r ` �.,' Zip Code: 3
Phone: �� �/S`7 �•- Email:
Contact/Rep. Name: Phone:
Email:
Plumbing Contractor Authorized Signature: }-
COPY fY g 4 >------ _ _.. _.__._.._ Date:
A co 0 our state re istration license is required to be on e. 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: % S L ` t
-OR-
What type of Property: ❑ Residential p. Commercial
Cost of job: $
Description of work: t,
4. Fees: Check all that apply:
❑ Gas Line = $65
❑ Water Heater = $65
❑ Sewer Line = $65
❑ Water Line = $65
❑ Lawn Sprinklers/Backflow device = $65
❑ Gray Water Systems= $130
Lot #: _ Block #: _ Subdivision:
At � a L., . " , ' )
❑ Hydronic Heating= $65 + ($10 x # of
manifolds/zones) = $
' Miscellaneous/Requested inspection = $65
❑ Sewer Turnaround (septic to city) = $65
Inspection fees can be bundled upon request. Re-inspectfees 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 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.
r. .e
. 1
Applicant's Name (print):
Signature: % 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 — f20R1 'M 72a1