BP5501Application Date
B~JILDING PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16th Street 5 5 01
Blair, Nebraska 68008
(402) 426-4191 Permit
/ /~j 2 ~ ~ ~ D~
~`~" / ~ Issue Date: ~ ~~ ~ ' ~~ Permit Fee: $
JOB ADDRESS O~
1 , LDEGAL LOT NQ~ Z BLK. ~~ TRACT ,p ~ ~^ SEE ATTACHED SHEET
2. WNER ~ ~ ~ ~ C ~M ILA RESS ~~m ~ ~ ZIP U ~P~ ~ ~ ~~ ~~
r3 CON RA TOR (j, ILADDRESS I PH~~ ~ ~~ P SE'NO~~ ~~ Q'
~
USE OF BUILDING
4.
5. Class of Work: ^ NEW ^ ADDITION ^ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work:
7, Sq. Footage of Structure pnduding Basement ana ` ge):
8. Change of Use From: Change of Use To:
g, Valuation of Work: $ ~ ~~ ~ °--
lain: FI°oaway Yes ^ No ^
10
Flood Dev. Permil Elev. Cen.
.
p
Fringe Yes^ No ^ BFE
11. Current Zoning: Site Plan Attached ^ Com I e Pla tt~ched ^
a~
~
12. State Fire Marshall Required: Yes ^ No^ -
Approximate Completion Date
Inspections Required and Fees
13. Special Use Permit Required: Yes ^ No ^ utilities
Sewer Tap Water Tap
14. Variance Required: Yes ~ No ~ Sewer Water Service
15. Minimum Setbacks: Front Side Rear Septic Remote
16. Sidewalk Required: Yes^ No ^ Waiver Approved Building
AP LIC TION ACCEPTED BY PLANS CHECKED BY APPROVED FOR ISSUANCE BY Footings Drywall
(before finish)
NOTICE
Separate permits are required for electrical, plumbing, heating, ventilating and air condi-
ment of the
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tinning, and septic systems. By my signature ca
ectr
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 Rough-in Fixtures
have received a copy of this application form signed by the Building Inspector and stamped
'APPROVED'. Final Permanent Service
I hereby agree to perform the proposed work in accordance with the speafications set forth
above and in accordance with the codes~ordinances of the City of Blair and the State of
Temporary Service
Nebraska. I understand that this permit is void if work is not commenced within 1(30 days
or is not cb pl In 2 years o of issue. Mechanical
Rough-in ABC
SI AT RE OF WNERfCONTRACTOR ORAUTHORIZED AGENT DATE Final
Plumbing
Ground Work
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Rev. 7091
CITY INSPECTION SLIPS
Inspection has been requested for ~~~ ~ ~~~~ ~~
Location of Building
By ~ ~.~ r ,t~ ~"6 ~-l~ ~~
Name of Company ^ // ~ ~~
on ~L -~~ C~~ - ~~ UGLL°i
Type of Inspection
Date Time
Results of the Inspection are: /~
~~
C ty Representative
i
r
1 ,
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