BP5532BUILDING P~RMITAPPLI
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
(402) 426-4191
Permit 5 5 3 2
Application Date: / y ~G/ ~`, Issue Date: ~ -r 1 S'%~ Permit Fee: $ ~~ - ®V
JOB ADDRESS t~~/ ti C ~~/Z~
T"`' l
LEGAL
1 ' DESCR. LOT NO. BLK. ~ TRACT
^ SEE ATTACHED SHEET
2 OWNER ~~~~~~ ~~ ~ ~ MAILADDRESS ZIP PHONE
3. CONTRACTOR ~~ ~ ~ ~ ` ~ t ~ MA~ADDRESS ~ ~ nO PHONE X
•I(_ 11// ~/ l ~/~~ ,LICE, NSE NO.
/!_- ~,LUO''_`~
USE OF BUILDING
4.
5. Class of Work: NEW ^ ADDITION ^ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work: a,~~ ~~ ~ ~ ~- ~ .
], Sq. FOOtage Of StrUCtUre (Including BasemenlandGarage):
8, Change of Use From: Change of Use To:
9, Valuation of Work: $
10. FIOOdplaln: Floodway Yes ^ No ^ Dev. Permit
Fringe Yes^ No ^ BFE Elev. Cert.
11. Current Zoning:
12. State Fire Marshall Required: Yes C~' No^
13. Special Use Permit Required: Yes ^ No ^
14. Variance Required: Yes^ No^
Site Plan Attached ^ Complete Plans Attached ^
Approximate Completion Date
Inspections Required and Fees
Utilities
Sewer Tap Water Tap
Sewer Water Service r~.Q ~~/~.~C
15. Minimum Setbacks: Front Side Rear
16. Sidewalk Required: Yes^ No ^ Waiver Approved _
CHECKED BY I APPROVED FOR ISSUANCE BY
NOTICE
Separate p mils 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 Inspectorand 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 t completed within 2 years of date of issue.
SIG TURE OF OWNER~CONTRACTOR OR AUTHORIZED AGENT DATE
~,
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE
Septic Remote
Building
Footings Drywall -
(beforefinish)
Framing
Rough-in
Final
Temporary Service
Rough-in
Final
Plumbing
Ground Work
Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
CATION
Final
Electrical
- Permanent Service
Mechanical
ABC
Fixtures
Comment:. ~ ff `T'om s ~ ~ ~~ ~' ~t~s Approve ~y
~~ ~~~~~
~o~r tiHPi~ tU
4518 SOUTH 133RD STREET / P.O. BOX 37769 / OMAHA, NEBRASKA 68137 / PHONE: (402) 330-5170
FAX: (402) 330-2373
June 28, 1993
ATTN: KATHERINE SORENSEN
LANDMARK INN
1465 FRONT ST
l3LAIR NE 68008
___ .... .
RE : Landmark Inn' .__. ,._ ti._ ~_ :_ _... _.~..._,.:,._.__ ._.___. _ .. _ .-~- ._ .
1465 Front St -
Blair NE C-3540.
Dear Katherine:
As you are aware, the underground fire service main is not a part
of our contract, however, we feel obligated to advise you that a
state law has recently been passed effective January 1st, 1990
requiring that "Contractor's Materials & Test Certificate for
Underground Piping" must be completed by the installing
contractor and attached to the sprinkler riser. Failure to
provide this form will prohibit the issuance of a certificate of
occupancy.
Sincerely, Zoo ~ s ~ ~~ ~. ~r ,
<_
` John Stover, Designing Engineer
CONTINENTAL FIRE SPRINKLER COMPANY
_.~__._,____ __ __.....JS[.pke__._
~L ~
`~~
c.e~ ./~2u ~°
.~~
~ ~~
Fire Sprinltler Company
~.
.~G...~.
~~
0l1 fi~e~ ~R Fire Sprinkler Company
4518 SOUTH 133RD STREET / P.O. BOX 37769 / OMAHA, NEBRASKA 68137 / PHOl~E: (402) 330-5170
iJ c^ •L- a l~ ca r ~ tiW t~ 4 1. ~3 ~:~ :3 FAX: (402) 330-2373
E' i. ~:3 t31:~ U'I` I-I :L f ~ T I••i 5'I` f2 E~ F•
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'•i`a Wham X•L- I~1<•~y f::artc°_a}r••r;
!~'rtcJ.a~.~:rc:l E?~.E•?c'i~Ei '~•i7';CI te_-3t t;~r~ti•Fic~tf%~.~ c:awEyr~ii-~r_~ tt-~E~ carnE~~.E?tEycl
i. n s •t <•:a 1 ]. ~ •~ i a ri Er f' t h N~ f i r~ e I~ t~ • a •Y: E:~ t. t a. a •r; Ey E:~ u i I:.t rn Es r ; t: Ea 7. r~ c:• Ey Ei i. yt
r~ w i r c~~ r., n C] ~ •L- a la e7 r~ 1 •~t• 4 1. `3 {:> :.s x
Fa ~r: y~ a ~_t r^ r~ a rt w Ft n i E ,7 c: ES 4 I::t :! ca ~:t !:> a 1° a r ~ w ~t r~ cJ y cr ~_t to :L ~~* t: t: e r-• c:; •C'
~ac.•lir7a~:t `c:iL~m~n•t.
~~~
ICE E. PRQWiV
f:v El r~ t i r; E ;-~ t ~ 1 F~ i r°• e `a ~ r~ i. •~°~ h :L ~.~ r-• C; G rn F~ ~t n y
CONTINENTAL FIRE SP.gINKLER CO. ',~^ ~~~a
P.O. BOX 37769 =
4518 SOUTH 133 STRf:ET CONTRACTOR'S MATERIAL & TEST CERTIFICATE FOR ~BOVE GROUND PIPING
' OMAHA, NEBRASKA 68137
PROCEDURE
Upon completion of work, inspection end tests shall be made by the contractor's representative and witnessed byan owner's representative. All defects shell be corrected and
system left in service before contractor's personnel finally leave the Job.
A certificate shall be filled out end signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. It is understood the owner's
representative's signature in no way prejudices any claim against contract3r for faulty materiel, poor workmanship, or failure to comply with approving authority's
requirements or local ordinances.
PROPERTY NAME DATE
LANDTYiARK I1VN L-•3540 6~9°93
PROPERTY ADDRESS
1465 FRUNT ST I~LRIR. NE
8Y APPROVING AUl HUHI7Its
PLANS INSTALLATION CONFORMS TO P
EQUIPMENT USED IS APPROVED
IF NO, EXPLAIN DEVIATIONS
~~ ^ NO
~S ^ NO
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS TO LOCATION ~~ ^ NO
OF CONTROL VALVES ANU CARE AND MAINTENANCE OF THIS NEW EQUIPMENT?
IF NO, EXPLAIf~~ /f %f
INSTRUCTIONS SIGNATURE ~' ~ ~V~ ~~~~
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON ~
1. SYSTEM COMPONENTS INSTRUCTIONS
2. CARE AND MAINTENANCE INSTRUCTIONS
3. NFPA 13A
DATE - /1/
PREMISES:
^ YES ^ NO
^ YES ^ NO
^ YES ^ NO
^ YES ^ NO
1
LOCATION
OF SYSTEM SUPPLIES BUILDINGS ~ //~ C ~/-/ / ?~
MAKE
MODEL YEAR OF
MANUFACTURE ORIFICE
SIZE
QUANTITY TEMPERATURE
RATING
SPRINKLERS / - QR 9~ l 'y /~,~
d `l ~ `P~ ~~ ~S
Q~ ~y 2 ~~
~a ~?.~ i y 2 ~6,~" .
PIPE AND /J
Type of Pipe 4 / ~ // L T
FITTINGS Type of Finings CQ,Sf ~~~~
.rte
ALARM DEVICE MAXIMUM TIME TO OPERATE
THROUGH TEST CONNECTION
ALARM
VALVE TYPE MAKE MODEL MIN. SEC.
INDICA~OR //
G~Jfi~'77`L/ '/ /
N ! Gr(/ /~C ~^
~3Yp
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
DRY
PIPE
OPERATING TIME TO TRIP
THRU TEST
CONNECTION'
WATER
PRESSURE
AIR
PRESSURE
TRIP POINT
AIR PRESSURE TIME WATER
REACHED
TEST OUTLET' ALARM
OPERATED
PROPERLY
TEST MIN. SEC. PSI PSI PSI MIN. SEC. YES NO
Without
O.O.D.
With
O.O.D.
., ~
IF NO, EXPLAIN
' MEASURED FROM TIME INSPECTOR'S TEST CONECTION IS OPENED
&5A (a-69) PRINTED IN U.S.A.
FORM p 5 Revised 1190
~~
,,,,~,`w...-
~7~,ND tC .L1~iI~~ ,, ~ ~,_; ~
~~~K „ ~~65 ~`RUi~~t' ~~:~ 't`3,~lx~ Lv~i~G~3'S4d~ t
rte!
~" OPERATION A~, , *-
^ PNEUMATI~ ^ ELECTRIC ^ HYDRAULIC
,/ ~ PIPING SUPERVISED ^ YES ^ NO DETECTING MEDIA SUPERVISED ^ YES ^ NO
-~;~ '~~ DOES VALVE OPERATE FROM THE MANUAL TRIP AND/OR REMOTE CONTROL STATIONS ^ YFS ^ Nn
u ...
DELUGE r!< IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO EXPLAIN
PREACTION
VALVES ^ YES ^ NO
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE
YES NO YES NO MIN. SEC.
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.6 bars) for two hours or50 psi (3.4 bars) above static pressure in excess
of 150 psi (10.2 bars) for two hours. Differential dry-pipe valve clappers shall be left open during test to prevent damage. All above ground piping
TEST leakage shall be stopped.
DESCRIPTION PNEUMATIC: Establish 40 psi (2.7 bars) air pressure and measure drop which shall not exceed 1-1/2 psi (0.1 bars) in 24 hours. Test pressure tanks
at normal water level and air pressure and measure air pressure drop which shell not exceed 1-1/2 psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT ~dU PSI for ~~ HRS. IF NO. STATE REASON
DRY PIPING PNEUMATICALLY TESTED / ~f7 ^ YES ^ NO
EQUIPMENT OPERATES PROPERLY Jf. ~ %~ j C~f'YES ^ NO
~I~z
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR
DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR
STOPPING LEAKS?~YES. ^ NO
TESTS DRAT REAIDING OF GAGE LOCATED NEAR SATE ~ ~ RESIDUAL PRESSURE N/ITH VALV h EST
TEST SUPPLY TEST CONNECTION: PSI CONNECTION OPEN SIDE ~ PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER
PIPING. t.°
VERIFIED BY COPY OF THE U FORM NO. 858 ^ YES ^ NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPINKLER PIPING ^ YES ^ NO
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS G~ C
WELDED PIPING ^ YES /~ ry~
F YES ...
~ DO YOU CERTIFY AS THE SPRINKER CONTRACTOR THAT WELDING PROCEDURE COMPLY
WITF1rTHE E,QUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR-3 - ^ YES ^ NO
~
d ~j; f ~ /!!/~~"~
~~'~ ' DO YOU O
R~IFY~~T,,,H~AT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN
G~OM
A
~~
l
- L PLI
N
Vt
l'TH:TH~tEQUIREMENTS OF AT LEAST AWS D10.2, LEVEL AR-3 ^ YES ^ NO
WELDING DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A DOCUMENTED
QUALITY CONTROL PROCEDURE TO INSURE THAT ALL DISCS ARE RETRIEVED
THAT
,
OPENINGS IN PIPING ARE SMOOTH, THAT SLAG AND OTHER WELDING RESIDUE ARE
REMOVED, AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED ^ YES ^ NO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) CUTOUTS (DISCS) ARE RETRIEVED? ~~ ~ - - ~ ^ NO
HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN
DATA
NAMEPLATE .~'
/LJ YES ^ NO _
~ ~
d `+
uH ~ Ltr I Irv SERVICE W TH ALL CO~NTR~~OL~ V~A~LVES OPEN:
~~, , .REMARKS -~l;,A!"V VVJ _
_ J ' ' j ~~
'PROPERTY NAME: ~ ~ ,- j ~ n n ~ ^/ ' s' d`'~7 ~~/
NAME OF SPRINKLER CONT CTOR _ Csv (/~ - ~ n 93 ~~
CONTINENTAL FIR SPRINKER CO. ~ ~/~ /ni
TEST iNESS~ Y
SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE
~'
FOR SPRIN ER CONTRAC~ GNED) TITLE DATE y
~s ~Z--~3
ADDITIONAL EXPLANATION AND NOTES:
DATE . - , .: `,
NOTE THIS SYSTEM HIGH PRESSURETES70FWATER@200PSIORAIR@40 PSI WITNESSED ANDVERTIFIEDBYTHEABOVE,SUBSTANTIATES
THAT THIS PIPING SYSTEM DOES NOT HAVE ANY DEFECTIVE FITTINGS, PIPE OR COUPLING AFTER COMPLETIONOFTHISTEST.IFTHIS
SYSTEM IS A WET SYSTEM, ADEQUATE HEAT TO PREVENT FREEZING OF WATER IN THE SPRINKLER PIPING IS THE C~PLETE
RESPONSIBILITY OF OTHERS. - E;;
LOW AIR ALARM SWITCH INSTALLED YES ^ NO ^
TAMPER SWITCHES INSTALLED YES~^ NO ^
~ese Edman IF NO STATE REASON: