BP5623- BUILDING PERMITAPPLICATIO~iV
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 5 6 2 3
(402) 426-4191 Permit
Application Date: I ~ - ~` ~ C1~ Issue Date: I ~' ~~ ^ ~~ Permit Fee: $ /,S C.~ p
JOB ADDRESS
~5~>Z W~ hen ~~
LEGAL
1 ' DESCR. LOT NO. BLK. TRACT
^ SEE ATTACHED SHEET
OWNER MAIL ADDRESS ZIP PHONE
3. CONTRACTOR / ~ MAILADDRESS PHONE LICENSE NO.
r~ ~ ~ i~T~ e~-~~ ~~ ~~~~~G -'
4. USE OF BUILDING
5. Class of Work: NEW ^ ADDITION ^ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work: ~~~~ ~• c C(~c,c,r-/1 ~
], Sq. FOOtage Of StrUCture (Including Basement end ara
r'
8. Change of Use From: Change of Use To:
g, Valuation of Work: $ ~1~,3(j~
10. Floodplain: Floodway Yes ^ No p Dev. Permit Elev. Cert.
Fringe Yes^ No ^ BFE
11. Current Zoning: ~', ~- ~
12. State Fire Marshall Required: Yes ^ NoO~
13. Special Use Permit Required: Yes ^ No 0~
Site Plan Attached Complete Plansached ^
Approximate Completion Date . ~ r..~~~~-.1ti S
Inspections Required and Fees
Utilities
Sewer Tap Water Tap
14. Variance Required: Yes ^ No [~--
15. Minimum Setbacks: Front ~ Side ~ Rear ~~
16. Sidewalk Required: Yes^ No [~ Waiver Approved
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. By 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 copy of this application form signed by the Building Inspector and stamped
'APPROVED'.
I hereby agree to perform the proposed work in accordance with the specifications set forth
above and in accordance with the codes~ordinances of the City of Blair and the State of
Nebraska. I understand that this permit is void if work is not commenced within 180 days
or is n mpleted w' hin 2 years ofd a of issue.
g~ '
$ G RE OF OWNE~GGNTRA"CT~A~OR~4U HORIZED AGENT DATE
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE
Sewer Water Service
Septic
Remote
Building
Footings Drywall
(before finish)
Framing Final ~'~ ~~-C~~
Electrical
Rough-in Fixtures
Final Permanent Service
Temporary Service
Mechanical
Rough-in ABC _
Final
Plumbing
Ground Work
Rough-in Final ,
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
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CITY INSPECTION SLIPS
Inspection has been requested for d/ Jl
/ ~ Lo atio of Building
By ~l
ame ~o fn Comp any
On c~-~ ~ M "
Type of Inspection
Date Time
Results of the Inspection are:
t (.c~~~
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City Representative