BP5219BUILDING PERMIT APPLI
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
(402) 426-4191
N° ~ X5219
Permit
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Application Date: ~ ~o'"~~~ Issue Date: Permit Fee: $ ~•
JOB ADDRESS n/~ ~
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LEGAL
1' DESCR. LOT NO. BL TRACT
^ SEEATTACHEDSHEET
OWNER /~ / MAILADDRESS ZIP PHONE
3. CONTRACTOR MAILADDRESS
N~ i. ~ ~S,,~GLc~~ //'72 _s ~~~ ~~~ PONE LICENSE NO.
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USE OF BUILDING
4.
5. Class of Work: NEW ^ ADDITION ^ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work: ~~~ ~~ _ ~~~~~~,
], Sq. FOOtage Of StrUCtUfe (Including Basement and Garage):
$, Change of Use From: Change of Use To:
g, Valuation of Work: $
10. Floodplain: Floodway Yes^ No ^ Dev. Permit
Fringe Yes^ No ^ 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 _
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 notconstitute 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 codesJordinances 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's not co pleted within 2 years of ,ate of i sue.
SIGNATURE OF OWNERJCONTRACTOR OR AUTHORIZED AGENT DATE
Site Plan Attached ^ Complete Plans Attached ^
Approximate Completion Date
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 ABC
Final ~'• C)C
Plumbing
Ground Work
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
CATION
Comment: Approve B ~
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