BP5111BUILDING PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 ~}Q 5111
(402) 426-4191 Permit
Application Date: ~ (J'ZC.~ ~(~ Issue Date: ~() r2G "G~ Permit Fee: $ /~t~U
JOB ADDRESS
1
LEGAL
1 ' DESCR. LOT NO. BLK. TRACT
^ SEE ATTACHED SHEET
ZIP PHONE
2, OWNER ~a C~ ~~~- MAILADDRESS
.~
3, CONTRACTOR~
~
~ ~ ~~~ ~ ,~1A~L~ QR~ SS ~Q~ 4 ~ I ~x/ ~' 2- HONG Ems' / r? ( " ~ ~2 aE NO.
(-(~~ /`L, ~„C/N~"~/
USE OF BUILDING
4.
5. Class of Work: ^ NEW ^ ADDITION ALTERATION ^ REPAIR ^ MOVE []REMOVE
6. Describe Work: ~ ~ /'1(/jj(~J
], Sq. FOOtage Of StrUCture (Including Basement and Garage):
8, Change of Use From: Change of Use To:
g, Valuation of Work: $ a ~d ~
10. Floodplaln: Floodway Yes ^ No ^ Dev. Permil Elev. Cert.
Fringe Yes^ No ^ BFE
11. Current Zoning:
12. State Fire Marshall Required: Yes ^
13. Special Use Permit Required: Yes ^
14. Variance Required: Yes ^ No ^
Site Plan Attached ^ Complete Plans Attached ^
No ^ Approximate Completion Date ~~-~" 7
Inspections Required and Fees
No ^ Utilities
Sewer Tap Water Tap
Sewer Water Service
15. Minimum Setbacks: Front Side Rear
16. Sidewalk Required: Yes^ No ^ Waiver Approved _
BY I PLANS CHECKED 8Y 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 acopy 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 Blair and the State of
Nebraska. I understand tha is ermit is void if work is not commenced within 180 days
of is not.complete~0u'tG~~~of date of issue. / i
E OF
AGENT
Septic Remote
Building
Footings Drywall
(before finish)
Framing Final 2- ~ 4 ~
Electrical
Rough-in Fixtures
Final Permanent Service
Temporary Service
Mechanical
Rough-in ABC
Final
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 ~