BP5857BUILDING PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 5857
(402) 426-4191 Permit
Application Date: 5_ C,( - 9 q Issue Date: J5— [C) 3 [ Permit Fee: $ 1,5 ,00
JOB ADDRESS i I o �
LEGAL 1
' DESCR.
LOT NO.
BLK.
TRACT
❑ SEE ATTACHED SHEET
2.OWNER �Lr
MAILDRESS DRES
ZIP 5 �3
�J � � � PHONE
[�
3. CONTRACTOR
MAILADDRESS
PHONE
LICENSE NO.
4. USE OF BUILDING
5. Class of Work: NEW ❑ ADDITION ❑ALTERATION
❑ REPAIR
❑ MOVE ❑ REMOVE
6. Describe Work: (__Q_I
Wood
L1, 2 � ! J,�au,
Li ink-
7. Sq. Footage of Structure (Including Basement and Garage):
8. Change of Use From:
Change of Use To:
9, Valuation of Work: $�
10. Floodplain: Floodway Yes ❑ No ❑
Fringe Yes No ❑
Dev. Permit
BFE
Elev. Cert.
11. Current Zoning: R M 1i
12. State Fire Marshall Required: Yes ❑ NoEf—
13. Special Use Permit Required: Yes ❑ No [T_
14. Variance Required: Yes E] No0-
15. Minimum Setbacks: Front Side Rear
16. Sidewalk Required: Yes ❑ No []'fiver Approved
BY I PLANS CHECKED BY I APPROVED FOR ISSUANCE BY
I 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 with the specifications set forth
above and in accordance with the oodes/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 ls4t'Ompleted within 2 vearsvod date of issue.
OFMNERICONTRACTOR OFrAUTHORIZED AGENT DATE
Site Plan Attached ❑ Complete Plans Attached ❑
Approximate Completion Date
Inspections Required and Fees
Utilities
Sewer Tap Water Tap
Sewer
Septic
Footings
Framing
Rough -in
Final
Temporary Service
Rough -in
Final
Ground Work
SIGNATURE OF OWNER (IF OWNER BUILDER) DATE I Rough -in Final
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Water Service
Remote
Building
rywa�
(befo inish)
Final
rical
Fixtures
— Permanent Service
Mechanical
AkC
Plumbing
Comment: Appro e By D -^
��• � LNC
C
CITY OF BLAIR
Application for Building Permit
PLOT PLAN
Address Date
Legal Description: Lot Block Addition
Please show all measurements of existing and contemplated structures,
also show distances between structures, etc., and property lines.
Is this a corner lot?
l?
e\ Q
v
a
cate North
5O`
_ —Center Line—of — _ — ��/ Street— _ �) %�/
Applicant