BP5189BUILDING PERMITAPPLI
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
(402) 426-4191
CAT101V
Permit
Na --5189
Application Date: ~ ~' ~~~ ~ ~ Issue Date: 1 Z 3Cj -~~ Permit Fee: $ C~-Crv
JOB ADDRESS
LEGAL
1 ' DESCR. LOT NO. BLK. TRACT
^ SEE ATTACHED SHEET
OWNER D ~/~ ~~ MAILADDRESS
2. ZIP PHONE
3 CONTRACTOR I / ~ MAILADDRESS ~ ~ ~ ~ / ~ PHONE ~ !~' A N ~ LICENSE ~.~
~CK-1'/ t~CJ ` uT3
USE OF BUILDING
4.
5. Class of Work: ^ NEW ^ ADDITION ^ ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work: ~, ~ ~~
]. Sq. FOOtage Of StrUCture (Including Basement and Garage):
$. Change of Use From; Change of Use To:
g, Valuation of Work: $
10. Flood lain: FI°Ddway Yes ^ No ^
p Fringe Yes^ No ^ Dev. Permit
BFE Elev. Cert.
11. Current Zoning:
12. State Fire Marshall Required: Yes ^ No^
13. Special Use Permit Required: Yes ^ No ^
14. Variance Required: Yes ^ No ^
15. Minimum Setbacks: Front Side Rear
16. Sidewalk Required: Yes^ No ^ Waiver Approved _
ACCEPTED BY I PLANS CHECKED BY I APPROVED FOR ISSUANCE BY
NOTICE
Separate permits are required for electrical, plumbing, heating, ventilating and air condi-
tioning, and septic systems.l3y my signature below, I achnowledge that payment of the
building permit application fee does not constitute issuance of this building permit. I further
agree that construction covered by this permit application.shall not be commenced until I
have received a copyof this application form signed bythe Building Inspectorand stamped
'APPROVED'.
I hereby agree to perform the proposed work in accordance with the specifications set forth
above and in accordance Wlth the codes~ordinances of the City of Blair and the State of
Nebraska. I understand that this perms is void}f work is not commenced within 1 SO days
or of completed with) years o of 'sue.
~-
SI NATURE OF OWNERf NT ACTOR 0 AUTHORIZE AGENT DATE
Site Plan Attached ^ Complete Plans Attached ^
Approximate Completion Date I `~C) '~
Inspections Required and Fees
Utilities
Sewer Tap Water Tap
Sewer Water Service
Septic Remote
Building
Footings Drywall
(before finish)
Framing Final ~ ~~~
Electrical
Rough-in Fixtures
Final Permanent Service
Temporary Service
Mechanical
Rough-in q~C
Final -~~
Plumbing
Ground Work
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Comment: Approved y; <
~.
'OUNDS PRTG: Blelr, NE Rev. 10/5