BP5922BUILDING PERMITApPLICATIO~iV
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 5 9 2 2
(402) 426-4191 Permit
~ t ~~~ Issue Date: / -' ~~~ ~L/ Permit Fee: $
Application Date: (~
_ f
l c.~~
JOB ADDRESS
d~~ ~
LEGAL
1' DESCR. LOT NO. BLK. TRACT ^ SEEATTACHEDSHEET
2, OWN MAIL ADDRESS ~/~`~1 ~
~J 6
`'L
~ J P
(~
~ PHONE
~ ~ MAILADDRESS
3, CO
~' ~~ PHONE
~ LICENS _
~ i ~'/3
USE OF BUILDING
4.
5. Class of Work: ^ NEW ^ ADDITION ^ALTERATION ^ REPAIR ^ MOVE ^ REMOVE
6. Describe Work:
], Sq. Footage Of Structure (Inducting Basement an arage):
$, Change of Use From: Change of Use To:
g, Valuation of Work: $ ~ ~ r~~
10 Floodplain: Floodway Yes ^ No Q 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
1 ~, 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 by the Building Inspector and stamped
'APPROVED'.
I hereby agree to perform the proposed work in accordance wish 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 ~- of cow ed wi years of to f i sue.
SIGNATURE OF OWNER~CONTRACTOR 0 AU RIZED AGENT DATE
Site Plan Attached ^ Complete I ~s At c ~ -
Approximate Completion Date
Inspections Required nd Fees
Utilities
Sewer Tap Water Tap
Sewer Water Service
Septic Remote
Building
Footings Drywall
(before finish) G, r~~ ~`I
I
Framing Final
Electrical
Rough-in Fixtures
Final Permanent Service
Temporary Service
Mechanical
Rough-in ABC
Final
Plumbing
Ground Work
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE ~ Rough-in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Comment: Approved
~-~
'OUNDS PRTG: BIeU, NE Rev. 10)9
r
BUILDING INSPECTIQN,~;EPORT