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CITY OF BLAIR — MISCELLANEOUS BUILDING PERMIT
9 PromiS
Permit #
Date: / "-� �� Approximate Completion Date: 6 Site Plan Attached:
Estimated Valuation of Project:
Application for: Permit Fee $40 + Issuance Fee $25 + $50 Deposit Fee: $115.00
Egress Window (floor plan drawing required)
Fences (plot plan required)
Gazebos (plot plan required)
Patios/Driveways/Sidewalks (new or replacement)
Roof ing/Siding/Soffit and/or Eave Repair/Gutters
Swimming Pools with Fence (plot plan required)
Window/Door Replacement (size change only)
Miscellaneous Building Permits (items not covered by one of the above)
Description:
Utility Excavation and Curb Grinding Fee: $75 plus bond
Curb Grind
Length
Utility Excavation
Length Lin. Ft.; Width Lin. Ft
Type: Water ; Sewer ; Other
Amount of Bond Posted: Bond Check #
(Curb grind - $9.00 per Lin. Ft.; Utility Excavation - $6.00 per Sq. Ft.)
Additional Description of project if necessary:
Cl I ZI �
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Legal Description (if applicable)
Owner: Address:Phone#:
Contractor:
Phone #:
Address: Cell #:
PERMIT RENEWAL FEE:
This fee is based on the amount of the original permit fee and is charged when work is not
completed within two years and the permit expires. Renewals will only be allowed with the
stipulation that all exterior site work and outside finish work is completed and interior life -
safety issues have been properly address. Permit renewals are for one (1) year, with a
maximum of two (2) renewals for a maximum permit span of four (4) years.
Original valuation of $0-$50,000 $150.00 $
Original valuation of $50,000 - $100,000 $200.00 $ 6� 00
Original valuation of $100,000 - $500,000 $300.00 $
Original valuation of $500,000 or more $400.00 $
Issuance Fee:
$ 25.00 = ; R,5 6-" �>
$ 50.00
Total Renewal Remit Fee = Permit Fee + Deposit + Issuance Fee $ ,k9 75
Separate permits are required for electrical, plumbing, hearting, ventilating and air conditioning, and septic
systems. By my signature below, I acknowledge this building permit application 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 a permit signed by the Building Inspector. 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 not completed within two (2) years of date of issue.
,S
Signature of Owner/Contractor Date
For Office Use Only WHERE PROPERLY VALIDATED (BELOW) THIS IS YOUR PERMIT
Date Permit Paid: `=a%`� % Receipt #-��C�-a %Approved by: %fir'
RECEIVEDOF:
ADDRESS
CITY, STATE, ZIP CODE
THANK YOU KEEPTHIS COPY FOR YOUR RECORDS.
NO
RECEIVED BY
Pounds Printing, Blau, NE 68008
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PLUMBING PERMIT APPLIC IQ
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008 F
Fax (402) 426-4195lP: P P 1813
(402) 426-4191 „
Application Date: 4 L3
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Permit Fee: $
Job Address ji (� A r
lJto CC) I _ CULL, IS.
O ail Address Zip ZI ne
Contract Mail Addre s Zip Phone
2. l_�_,
3. Class of Work: O COMMERCIAL 01ESIDENTIAL I O New ddition O Alteration O Repair O Replacement
4 escribe �ork:r vo to �
PLUMBING PERMIT FEES
Comments:
Modular Home ......................$50.00
Type of Fixture No.
j
Kitchen .............................. $8.00 x
Bath..................................$8.00 x h '
Rough -In Bath......................$4.00 x I �•
Additional Sinks....................$3.00 x
Laundry/Drain ......................$5.00 x _ S. 0 (7
Water Heater ........................$3.00 x
Outside Water Faucet..................$3.00 x
Notice
Drinking Fountain .......................$3.00 x
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of
Backflow/Grease Trap............ $10.00
work will be complied with whether specified herein or
Water Service ......................$10.00'
not. The granting of a permit does not presume to give
authority to violate or cancel the provisions of any other
Sewer................................$10.00
state or local law regulating construction or the
performance of construction.
Groundwork ........................$10.00
Septic Tank & Laterals........... $10.00
Lawn Sprinkler System ............ $10.00
Sprinkler System (Commercial). $30.00
Gas/Water Piping System
(Commercial).......................$30.00
Signature of Contractor or Authorized Agent
Permit Issuance Fee................$20.00
0
Current License on File O Yes O No ,N A
Date
Comment:
WHEN PROPERLY VAL1DAr ED (IN THIS SPACE) T l UR PERMIT
Approved By: �� "^°� 9 F�!
ELECTRICAL PERMITAPPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
Fax (402) 426-4195
(402) 426-4191
Application Date: V
E 2873
Permit Fee: $
Job Address •
` 03 � C�
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6 �
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Zip
Phone
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Contracpar Mail ress
Zip
Phone
2.
3. Class of Work: O NEW RESIDENTIAL O NEW COMMERCIAL REMODELING/ADDITIONS O UPGRADE SERVICE
Work: �-C °(@j
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4escribe
5.Current License on File O Yes O No O N/A
Completion Date
ELECTRICAL PERMIT FEES
Service Fee = (Amp Fee + 2.00 per branch circuit)
Upgrade Existing Service.............$10.00
1-100 Amp Fee .......................$13.00
Temporary Service............ .. $10.00
.....
101-200 Amp Fee .......................$18.00
201-300 Amp Fee .......................$30.00
Fire Alarm System............ ......$10.00
301-400 Amp Fee .......................$42.00
Signs ...................................... $15.00
401-500 Amp Fee .......................$55.00
Miscellaneous Apparatus .............. $11.00
501-600 Amp Fee .......................$67.00
AC/DC Circuit ........................... $5.00
601-700 Amp Fee .......................$80.00
Commercial/Multi Family and All Upgrades:
701-800 Amp Fee .......................$92.00
801-900 Amp Fee.....................$105.00
ff of Circuits x $2.00
901-1000 Amp ........................$117.00
Amp Fee
IF OVER 1000 Amp
1" 1000 Amp Fee..................$117.00
Amp Fee + Circuit Total
Each additional 100 Amps ......... $13.00
New Residential: (Finished Area)
Single/Two Family Dwellings
Notice
sq. ft. x.045
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
Modular/Manufactured Homes ...... $50.00
provisions of laws and ordinances governing this type of
Receptacle/Switch Outlets `
work will be complied with whether specified herein or
Fixtures 1- $.75
ff
not. The granting of a permit does not presume to give
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authority to violate or cancel the provisions of any other
SInoke Detectorsx $3.00
2,--) .CXR
state or local law regulating construction or the
Residential/Commercial Appliance
performance of construction.
# Fixed Outlets x $3.00
Motor(s) x $3.00
Power Apparatus (220 Volts)
I
t)C)C-)
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#Apparatus x $5.00
ignahire of Contractor or Authorized Agent
Q �
Permit Issuance Fee....................$20.00
Total
I�J�I 7!�;
Date
Comment:
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Approved By: i'W/L
K Lk
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
Fax (402) 426-4195
(402) 426-4191
Application Date 9 -5 DV
M 1632
Permit Fee: P60"?
Job Address—L
Ow
'Lavij
a 1 Address
V
Zip
Phone
Contract! . Mail Address
2.,�
Zip
Phone
3. Class of Work: ❑ COMMERCIAL RESIDENTIAL
O New Addition O Alteration O Repair O Replacement
Describe Work:
4. 4g
CS
MECHANICAL PERMIT FEES
Central A/C :2� 3 Tons
,11
Furnace �U b�� BTU/H
Forced Air/Heat Pump Systems — Per Unit'
-Commercial/Residential (New)....�....................... ,,,,,,,,,,,,,,$25.00
# of Units Dili 6t A/C
r�
b
Furnace
Air -Conditioner Unit — Per Unit
Commercial/Residential (New).................................*.'.........$10.00
I ` `
Completion Date:
Forced Air Systems/Air Conditioner
u °
Unit Replacement Per Unit Commercial/Residential .................$10.00
Refrigeration Units/Coolers/Lines/Compressor -
Per Unit Commercial (New or Replacement)..........................$10.00
Comments:
Appliance Vent/Fans .......................$10.00
((�•
Boiler ......................................... $15.00
Notice
I hereby certify that I have read and examined this
Duct System ................................. $10.00
�J
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of
Gas/Air Outlets ....................... x $2.00
work will be complied with whether specified herein or
not. The granting of a permit does not presume to give
Radiant Heat Systems/Gas/Water
authority to violate or cancel the provisions of any other
Piping System...............................$25.00
state or local law regulating construction or the
performance of construction.
Modular Home .............................. $50.00
Permit Issuance Fee ........................ $20.00
1-0U,
Signature of Contractor or Authorized Agent
Total
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Current License on File Yes O No /A
Date
Comment:
WHEN PROPERLY VALIDATED (INTHIS SPACE) THIS 1S YOUR PEKMIT
Approved By: �E
1.
2
3
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CITY OF I)LAIQ_
ol
HOMEOWNER VERIFICATION FOR PLUMBING AND/OR
LMECHANICAL PERMITS
C�ai le S f
Print your full name on line above:
states the following:
I am the owner of the single family dwelling for which I am applying for a
plumbing and/or mechanical permit.
Address: ,?0 ✓�� C G%1� Y
I am applying for a plumbing and/or mechanical permit for a single family
dwelling and it is or will be my principal residence.
I will install and connect the plumbing and/or mechanical by myself, without
compensation or pay from or to, any other person.
4. I have sufficient knowledge of the 2006 International Code requirements to make
an electrically safe and mechanically secure installation, which will meet the
minimum standards referenced in the 2006 International Code.
5. I am aware of all inspections required prior to a final.
6. I will call twenty-four (24) hours in advance for an inspection. I am also aware
that it is not the inspector's job or duty to be my instructor in plumbing and/or
mechanical.
7. I am aware that violation of the code makes it a Class 1 misdemeanor to make a
false statement on a request for inspection.
8. By signing this form I am stating the above information is true an correct.
�/ 3 0
Homeowner/Applicant Signature Date
T®T
218 South 16th Street • Blair, Nebraska 68008 • 402-426-4191 • Fax 402-426-4195 • E-mail cityofblalr@cl,blalr,ne.us
Nkb
!OILOI
a y /-, s- , states the following:
print your full name on line above:
1. I am the owner of the single family dwelling for which I am applying for an
electrical permit.
Address: 6132 C0%4 sem'
2, I am applying for an electrical permit for a single family dwelling and it is or will
be my principal residence.
3. I will install and connect the electrical wiring for myself, without compensation
or pay from or to, any other person.
4. I have sufficient knowledge of the 2005 National Electrical Code requirements to
make an electrically safe and mechanically secure installation which will meet the
minimum standards referenced in 81-2104.
5, I am aware of all inspections required prior to a final.
6. I will call twenty-four (24) hours in advance for an inspection. I am also aware
that it is not the inspector's job or duty to be my instructor in electrical wiring.
7. I am aware that Nebr. Rev. Stat. 81-2143 makes it a Class 1 misdemeanor to
make a false statement on a request for inspection.
8. By signing this form I am stating the above information is true an correct.
Homeowner/Applicant Signature Date
s
218 South 16th Street - Blair, Nebraska 68008 - 402-426-4191 - Fax 402-426-4195 - E-mail cityofblair@ci.blair.ne,us P00.iVH Y
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BUILDING
, s ® IMPORT ®®r
,❑F CITY OF BLAIR ❑ WASHINGTON COUNTY(�/ ElOTHER
LOCATION OF INSP CTION . ( 1
NAME OF OWNER IN � t`� � f � J "` � � � �%� Ur,CONTRACTORS ��
DATE INSPECTION REQUESTED- F TIME INSPECTION REQUESTED- PERMIT NO-
TYPE
O':��
TYPE OF INSPECTION REQUESTED: `4 W CONFERENCE ❑ STATUS CHECK
BUILDING: ❑ FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL PASSED FAILED
El ElCOMMENTS: o or-'
UTILITIES: ❑ SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑ REMOTE ❑ WATER SERVICE PASSED FAILED
❑ PARTIAL ❑ ❑
COMMENTS:
ELECTRICAL: ❑
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑ TEMPORARY SERVICE ❑ PRECONNECT
PASSED FAILED
❑
PARTIAL
❑
❑
COMMENTS:
MECRANICAL: ❑
ROUGH -IN ❑ AIC ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL
PASSED
FAILED
1-1
-
PLUMBING: ❑
GROUNDWORK ❑ ROUGH -IN ❑ FINAL. ❑ WATER METER INSTALLED ❑ PARTIAL
-PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:.
❑ OCCUPANCY GRANTED ❑ CONDITIONAL' OCCUPANCY GRANTED-
NOTES/REMARKS.
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MUILDING
INSPECTION REPORT
` CITY OF BLAIR ❑ WASHINGTON COUNTY ❑ OTHER
LOCATION OF INSPECTION-
NAME
NSPECTION NAME OF OWNER` 111#61 � �� 1J� CONTRACTOR �
DATE INSPECTION REQUES_ G 6 TIME INSPECTION REQUESTED, � � PERMIT N0- /,
TYPE OF INSPECTION REQUESTED:
❑ CONFERENCE
❑ STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING G ❑ DRYWALL n INAL ❑ PARTIAL
PASS
FAILED
( �j�-/2L
El
COMMENTS:l
UTILITIES: ❑
SEWER TAP❑
SEWER ❑ SEPTIC ❑ WATER TAP E]REMOTE ❑ WATER SERVICE
PASSED
FAILED
. PA ,TIAL
❑
❑
COMMENTS. �' --
_
ELECTRICAL: "
ROU • H IN
AL ❑ PERMANENT SERVICE ❑ TEMPORARY SERVICE ❑ PRECONNECT
PAS§CD
FAILED
❑
PRTIAL
�� o cp-t rlY�
❑
COMMENT.
MECHAMICL
ROU HIN ❑
A/C ❑ FURNACE ❑ RADIANT HEAT � El PARTIAL
PAy�SG/'S//nr�y��
FAILED
/IN/A)L
t
El
PLUMBING:
❑ PRESSURE
0
❑ WATER METER INSTALLED ❑ PARTIAL
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
DATE OF INSPECTION
FAXED OPPD\BURT REA TO CONNECT SERVICE:
PASS? FAILED
Fes? ❑
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