BP5457°".~,3`~
UILDING PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 5 4 5 7
(402) 426-4191 Permit
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Application Date: ~ 'Z~ ° ~~ Issue Date:
Permit Fee: $ ~~ ~~
JOB ADDRESS ~ CI ~~ F
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1. LEGAL
DESCR. LOT NO. BLK. TRACT ~ SEE ATTACHED SHEET
2. OWNER ~
~~~ . Lj~r~ can ~-~;~ MAILADDRESS
~ ,~~~ ~~ ~c_n ZIP
N~~~ `PHONE
CCU ~5~~~~;
3 CONTRACTOR ~ ~ ~~ e MAILADDRESS ~ ~ /, ~ '
C l/L~ l ~~- ~P~N~~ <,.., X ~~ ~ ~/~L'~~CTn
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USE OF BUILDING
4.
5. Class of Work: NEW ^ ADDITION ^ALTERATION ^ REPAIR [~ MOVE ^ REMOVE
6. Describe Work: ~_~6 ~ ~! ~ Z~ ~f,S ~ C~ ~ ~_
7. Sq. Footage of Structure (IRdBaiRg BasamaRt aoa Garaga):
$, Change of Use From: Change of Use To:
g, Valuation of Work: $
Floodway Yes ^ No ^
10. Floodplain: Fringe Yes^ No ^ Dev. Permit
BFE
EIev.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. 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 bythe 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 it and the State of
Nebras a. I understand that his permit Is v i~ if work is noJ~omrp n d withinJ80 days
or is n~comelettxtlwithir~ears•~of da obtssue. a ,l / / /
~1GNATUR~ OF OWNERJCOJtV~fiACTOR OR AUTHORIZED AGENT ~ DATE
Site Plan Attached ^ Complete Plans Attached ^
Approximate Completion Da~ ~ ~~
Inspections Required and Fees
Utilities
Sewer Tap Water Tap
Sewer
Septic
Water Service
Remote
Building
Footings Drywall
(before finish)
Framing Final
Electrical
Rough-in Fixtures
Final Permanent Service
Temporary Service
Mechanical
Rough-in ~ ~ ABC _
Final ~'L
Ground Work Plumbing
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE ~ Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Comment: Approved By:
'OUNDS PRTG: Bleb, NE RBV. 10/B
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INVOICE
;`NUMBER DESCRIPTION DISTRIBUTION AMOUNT INVOICE
NUMBER DESCRIPTION DISTRIBUTION AMOUNT
1-10-42022 22.00 REFUND 0 PERMIT X15457
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Vendor Number
To IYIQ~ l~ ~-~~C-
(~20 ~ .~Z~ `C~l • ~X 7ln`7 -
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Voucher Number
Q232~fy _
Check Number
Clerk
Finena Committee Approval:
CITY OF BLAIR, NEBRASKA ~ 3 ~ ~~
Claim Date
I do edemnly swear flat the ebore eeeount Is true end correct to the best of my knowkdSe.
Subs<crWed and sworn to beforo me this day of 19-