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CITY OF BLAIR - APPLICATION FOR BUILDING PERMIT
Permit #
Date: / ~ ..;1;/- 0 r
Approximate Completion Date:
! ". -1 '7
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/;2-1 -- eJ q
REScheck Attached:
Complete Plans Attached
v
Site Plan Attached:
Application for: Residential Commercial/Industrial _
New Construction Manufactured Home Modular
Move-on: Home _ Accessory Building Other
Remodel Addition
Accessory Building: Garage _ Pole Barn_ Other
Floor Type: Dirt _ Concrete _ Electricity: Yes i/ No
Sign Erecting, Awnings ~ Decks/Handicap Ramps (plot plan required) _
Satellite Dishes/Radio Antenna/Cell Towers (plot plan required) _
Other
Utilities: Public Water: Yes_ No Private Well
If yes, responsible entity: Blair OPPD Line Kennard
Agreement needed: _ Date Agreement Received: _
Public Sewer: Yes_ No Septic Drawing Provided: _
If yes, responsible entity: Blair _ Kennard
County Road Permit Required: Yes_ No _ Submitted: Yes _ No _
Additional Description of project if necessary: J q II X I/,;; '.5 II (,1?tW1~ ~ ty/1 t
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Proiect Information:
Legal Description (if applicable)
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OwnEk:.~:l/~WI (l)t?tJ)/:, .;' 'J l
Contractor: '-I'lu (J/eA' a)U '
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8900 3913<-_80
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Job Address:
Phone#: ,-/;t..tJ; - L/ 72/
Phone #: I/2!J7 - 8t6.:z,
Address:
/!t/3
.St
( ;
Cell #:
[6 'dd--o~
Date
For Building Permits other than One & Two Family Residential Structures:
I hereby acknowledge and agree that I have/will submit a set of plans for this project to the Nebraska State Fire Marshal's Office for
Review.
Signature of Owner/Contractor
Date
ZONING REVIEW:
Zoning/Flood Plain/Utilities:
Current Zoning:
Conditional Use Permit Required: Yes _ No_
Date CUP Approved:
Yes No Variance Required: Yes _ No_
Second Front Side Side Rear_
State Fire Marshal Required:
Minimum Setbacks: Front
lot Sauare Footage:
length x Width:
lot Coverage %
Driveways/Sidewalks:
Sidewalk required: Yes_ No_
Sidewalk Waiver: Yes
Date Waiver Approved:
Preexisting Garage requires driveway to be less than 3' from property line: Yes_
Approved by:
No
Flood Plain: Yes No
If yes, specify special requirements:
BUilDING INSPECTOR REVIEW:
Number of Stories
One Two
Three
Four
>Four
High Rise (>75 ft)_
Type of Residential Structure:
Ranch _ Two Story _ Split Entry _ Raised Ranch _ Other
Rooms _ Bedrooms _ Bathrooms _ Fireplaces _ Gas_ Electric _
Egress in Basement: Required: Yes _ No _ Provided on Plans: Yes No
Sleeping Rooms Living Area Other Egress
Sauare Footage:
Main level:
Basement: (Unfinished)
Garage:
Detached Garage:
Addition:
Porch: Front
Deck that affect setbacks:
Second level: Third level
(Finished)
2 bay_ 3 bay_ 4 bay_ 5+ bay
Pole Barn:
Remodel:
Side
Front Side
Rear
Rear
Occupancy Classification:
Assembly, theaters, with stage Assembly, theater, without stage _
Assembly, nightclubs _ Assembly, restaurants, bars, banquet halls _
Assembly, churches _ Assembly, arenas _
Assembly, general, community halls, libraries, museums _
Business Educational Factory and industrial, moderate hazard _
Factory and industrial, low hazard _ High Hazard, explosives _
(section continued on next page)
High Hazard HPM
Institutional, incapacitated _
Institutional, day care facilities _
Residential, multiple family _
Residential, care/assisted living facilities
Storage, moderate hazard _ Storage, low hazard _ Utility, miscellaneous _
Institutional, supervised environment _
Institutional, restrained _
Mercantile Residential, hotels _
Residential, one- and two-family
Is building required to be protected by automatic fire sprinkler svstem?"
No
Only partially in some areas or rooms Please Specify
Yes _ If yes, the standard to which the sprinkler system will be designed:
NFPA 13 NFPS 13R NFPA 13D
Driveway Grade: 20% grade or less? Yes _ No_
(Dale witt review new residential construction. AI will review all second access requests and industrial and
commercial driveway requests)
Required Off Street Parking:
Permit Fee Calculation:
Building Permit Deposit Fee:
Commercial, new homes and residential
additions/remodels/accessory buildings valued $10,000 or greater $
Fee - $500,00
Residential additions/remodels/accessory buildings valued under $10,000 $
Fee = $200,00
All other permits Fee = $50.00 $
RESIDENTIAL - NEW CONSTRUCTION:
Permit fee is:
Finished sqjft area
(not including finished basement area)
Finished basement sqjft area
Unfinished basement sqjft area
Garage sqjft area
Total Valuation:
X$92
X$56
X$29
X$25
$
$
$
$
$
$
$
$
Total Valuation
Multiplied by 0,006 =
Issuance Fee:
25,00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee
RESIDENTIAL - ADDITIONS / REMODELS and 2 ~, (A ::: 5 C{ 0 I CO
COMMERCIAL - NEW CONSTRUCTION / ADDITIONS / REMODELS: '0
Business/lndustrialjEducational/ Assembly/Factory/Storage/Utility -::::: ((02- fPj. +1-.
*Porches with roofs/screened patios are considered additions
Construction valuation computation: Sqjft area X $63
Except for the following:
Accessory Buildings & Interior Remodeling Proiects: sqjft area X $43
Pole barns with no hard surface floor: sqjft area X $25
Sign Erecting! Awnings and Decks/Handicap Ramps: sqjft area X $25 (Minimum
valuation of $2000)
Construction valuation computation: , I
Finished sqjft area 2-. ~ ' b I
X$ oS-
$
112.';0
Construction valuation is ...................................Permit fee is:
$0 TO $50...........................................................$0
$51 TO $500........................................................ $25
$501 TO $2,000........................................................ $25 + $3 per additional $100
$2,001 TO $25,000........................................................ $70 + $13 per additional $1,000
$25,001 TO $50,000......................................................$370 + $10 per additional $1,000
$50,001 TO $100,000......................................................$620 + $7 per additional $1,000
$100,001 TO $500,000......................................................$970 + $5 per additional $1,000
$500,001 TO$1,OOO,OOO.................................................. $2,970 + $4 per additional $1,000
$1,000,001 AND OVER.................................................. $4,970 + $3 per additional $1,000
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Permit Fee calculated from chart above
$ as-.oO
Issuance Fee:
$ 25.00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee
$ ~(f).()()
Additional Comments:
Approved by:
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Date:
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Contingent On Approval by Fire Marshall
Meet IBC, IPC, IMC and NEC Code Requirements
Sleeping Rooms below Story and in Basement required to have egress
For Office Use Only
~D~t; ';;;it paid;\r:-~c,' -~~~.~~~~~~,~~~ ---~~~.~~~~~~~~
Permit Fee: > 0 v..l
Deposit Amount 50 u.;4
Receipt # d 5S'11
Deposit Paid by for return to:
Building Inspection Pouch given: Yes _ No ;<.
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BUILDING PERMIT DEPOSIT AGREEMENT
A $500,00 refundable deposit is being collected for any new commercial, new
residential, and any additions, remodels and accessory building valued $10,000 or
greater at the time of your building permit application.
A $200.00 refundable deposit is being collected for any residential remodel,
addition or accessory building valued under $10,000.
A $50,00 refundable deposit is being collected for all misc. permits.
The City reserves the right to not refund this deposit if any of the following
conditions occur during the construction period:
1) Theft of water service by the plumber, owner or general contractor.
2) All permits have not been obtained.
3) All required inspections have not been obtained.
4) Occupancy occurs prior to a final inspection.
5) The project is completed without a final inspection being done.
6) Storm Water Management Plan inspection not obtained. (If Required)
If any or all of these situations occur during construction, you may forfeit your
deposit.
I hereby agree to the above conditions, and understand that should any or
all of the above situations occur, the building permit deposit SHALL be forfeited or
discounted upon the discretion of the City of Blair, Building and Inspections
Department.
Contractor/Owner
City of Blair
//-16~()1
Date