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CITY OF BLAIR - APPLICATION FOR BUILDING PERMIT
Permit # 10
Date: -:�I A W D
Approximate Completion Date: (`
Site Plan Attached: REScIleck Attached: Complete Plans Attached
Application for Residential -1Z Commercial /Industrial
New Construction Manufactured Home Modular
Move -on: H,1`me Accessory Building Other
Remodel ✓ Addition
Accessory Building: Garage Pole Barn Other
Floor Type: Dirt Concrete Electricity: Yes 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 _
If yes, responsible entity:
Agreement needed:
Public Sewer: Yes No _
If yes, responsible entity:
County Road Permit Required: Yes No _
Project Information
Job Address:
Legal. Description (if applicable)
1
Owne C-CA I CCQ Address: Phone #: q2
Contractor: Phone #:4,)-& - q c I
Address:
Cell #:
Email Address for Contractor:
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 r n t complet within two (2 years of ate of issue.
l 1�
( Signature of Owner/Contract9il 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.
Private Well
Blair OPPD Line Kennard
Date Agreement Received:
Septic Drawing Provided:
Blair Kennard
Submitted: Yes No
L> 6 `I 7,
Signature of Owner /Contractor Date
ZONING REVIEW:
Zoning/Flood P lain/Utilities:
Current Zoning: Conditional Use Permit Required: Yes No
Date CUP Approved:
State Fire Marshal Required: Yes No Variance Required: Yes No
Minimum Setbacks: Front V Second Fron Side :j Side _q— Rear��
Lot Square Footage:
Length x Width: Lot Coverage
Drivewa rys /Sidewalks:
Sidewalk required: Yes No Sidewalk Waiver: Yes No
Date Waiver Approved:
Preexisting Garage requires driveway to be less than 3' from property line: Yes
Approved by:
Flood Plain: Yes No
If yes, specify special req, irements:
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: Second Level: Third Level
Basement: (Unfinished) (Finished)
Garage: 2 bay 3 bay 4 bay 5+ bay
Detached Garage: Pole Barn:
Addition: Remodel:
Porch: Front Rear Side
Deck that affect setbacks: Rear Front Side
Occupancv Classification:
Assembly, theaters, with stage _
Assembly, nightclubs
Assembly, churches
Assembly, general, community ha
Business Educational
Factory and industrial, low hazard
Assembly, theater, without stage
Assembly, restaurants, bars, banquet halls
Assembly, arenas
Ils, libraries, museums
Factory and industrial, moderate hazard _
High Hazard, explosives
(section continued on next page)
Business / Industrial / Educational / Assembly /Factory /Storage /utility
*Porches with roofs /screened patios are considered additions
Construction valuation computation: Sq/ft area X $63
Except for the following:
Accessory Buildings & Interior Remodeling Projects sq/ft area X $43
Pole barns with no hard surface floor sq/ft area X $25
Sign Erecting/Awnings and Decks /Handicap Ramps sq/ft area X $25 (Minimum
valuation of $2000)
Construction valuation computation
Finished sq/ft area —X$
$
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, 000, 000 ......................... .........................$2,970
+ $4
per additional $1,000
$1,000,001 AND OVER ......................... .........................$4,970
+ $3
per additional $1,000
Permit Fee calculated from chart above $ 90 00
Issuance Fee: $ 25.00 `i -A 0 �
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $
Additional Comments:
' f
Approved by: Date:
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
Date Permit Paid.
Permit Fee:
Deposit Amount
Receipt #
Deposit Paid by for return to;
Building Inspection Pouch given. Yes No
High Hazard HPM Institutional, supervised environment
Institutional, incapacitated Institutional, restrained
Institutional, day care facilities Mercantile Residential, hotels
Residential, multiple family Residential, one- and two - family
Residential, care /assisted living facilities
Storage, moderate hazard Storage, low hazard Utility, miscellaneous
Is building required to be protected by automatic fire sprinkler system ?"
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 will review new residential construction. Al 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 $
RESIDENTIA - NEW CONSTRUCTION:
Permit fee is:
Finished sq/ft, area X$92
$
(not including finished basement area)
Finished basement sq/ft area X$56
$
Unfinished basement sq/ft area X$29
$
Garage sq/ft area X $25
$
Total Valuation:
$
Total Valuation Multiplied by 0.006 =
$
Issuance Fee:
$ 25.00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee
$
Site Plan Attached: RESc4eck Attached: Complete Plans Attached
Application for Residential Commercial /Industrial — L I,
New Construction Manufactured Home Modular
Move -on: Fme Accessory Building Other
Remodel ✓ Addition
Accessory Building: Garage Pole Barn Other
Floor Type: Dirt Concrete Electricity: Yes 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 _
If yes, responsible entity:
Agreement needed:
Public Sewer: Yes No _
If yes, responsible entity:
County Road Permit Required: Yes No _
Job Address:
Legal. Description (if applicable)
_ Private Well
Blair OPPD Line Kennard
Date Agreement Received:
Septic Drawing Provided:
Blair Kennard
Submitted: Yes No
Owner ICJ�fC , �C�q�1Cl l�1 Address: Phone #: `���° "� ��
Contractor: <VV a -CAP' Phone # AR4 l
22q
Address:
Cell #:
Email Address for Contractor:
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 r i n t complet within two (2 years of ate of issue.
lo
( Sig nature of Owner Contract Date
Owner/
Contract
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
Project Information ccO
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RECEIVED OF:
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ADDRESS
CITY, STATE, ZIP CODE
Pounds Printing, Blair, NE 68008
CITY Of I)tAIQ
ZNM
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BUILDING PERMIT SUPPORTING DOCUMENTS
This building permit packet includes various items dealing with particular code
requirements and/or building permit requirements. It in no way includes ALL particular
code items. Also, it is your responsibility to know the 2006 International Building
Code requirements that apply to your project. Please understand this packet is only
designed and distributed to aid you in your building permit process. A copy of the
International Building Code is available for your use at the Blair Public Library.
I have read the above disclosure and accept this building permit documentation on my
own behalf assuming full responsibility as the owner /contractor for this project.
Contractor
City of Blair
ate
M. p N
218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 • Fax 402 - 426 -4195 • E -mail cityofblair @cLblair.ne,us TY
ELECTRICAL PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
th
Application Date:
3-ft-[o
218 South 16 Street
Blair, Nebraska 68008
Fax (402) 426 -4195
(402) 426 -4191
Is
bi dro
Permit Fee: $
Job Address
O �� t y t r ii Mail Address Zip P ' ho /�� e — 7
Cont rtor ail Address Zip Phone
2. c}C_-
3. Class of Work: O NEW O NEW COMMERCIAL REMODELING/ADDITIONS O UPGRADE SERVICE
J RESIDENTIAL
Describe o k$ l l �C4 f� '° 0 � c Q✓IG° t e�✓ ck,w Ui t;%
®� � �
5.Current License on File O Yes O No O N/A Completion Date
ELECTRICAL PERMIT FEES
Service Fee = (Amp Fee + $5.00 per branch circuit)
Upgrade Existing Service .............$25.00
1 -100 Amp Fee .......................$25.00
Temporary Service.................... $15.00
101 -200 Amp Fee .......................$35.00
201 -300 Amp Fee .......................$55.00
Fire Alarm System............. ......$15.00
..
301 -400 Amp Fee .......................$75.00
Signs ( each) .............................. $25.00
401 -500 Amp Fee .......................$95.00
Miscellaneous Apparatus .............. $15.00
501 -600 Amp Fee .....................$115.00
601 -700 Amp Fee .....................$135.00
Commercial/Multi Family and All Upgrades:
701 -800 Amp Fee .....................$155.00
801 -900 Amp Fee .....................$175.00
# of Circuits x $5.00 SOD
901 -1000 Amp . ........................$195.00
Amp Fee
IF OVER 1000 Amp
1 1000 Amp Fee ..................$195.00
Amp Fee + Circuit Total 3D.OD
Each additional 100 Amps ......... $20.00
New Residential: (Finished Area)
Single /Two Family Dwellings
Notice
sq. ft. x.063
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
work will be complied with whether specified herein or
Other: (alterations, additions and modifications)
not. The granting of a permit does not presume to give
Receptacles /Switches/Lighting Fixtures (110 volt only)
authority to violate or cancel the provisions of any other
# of Apparatus .......... i x $1.00 1 • ���
state or local law regulating construction or the
performance of construction.
Power Apparatus (220 Volt or higher)
# of Apparatus...... x $8.00
Smoke Detectors..... x $3.00
SignatGre of Contractor or A t fi rized Agent
_
Permit Issuance Fee ...................$25.00.
Total.
190 /D
Date
Comment:
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Approved By:
Rev. 2008 -10
PrOM15
0 ent BUILDING PERMIT DEPOSIT AGREEMENT
refundable deposit is being collected for any new commercial, new
and any additions, remodels and accessory building valued $10,000 or
e 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
Date
CITY OF I)tAIQ
se of
4
HOMEOWNER VERIFICATION FOR ELECTRICAL WIRING PERMITS
C;L , 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. l l
Address:
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 correct.
Ho s /Applicant Signature Bate'
218 South 16th Street - Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 - 426 -4195 - E -mail cityofblair @ci.blair.ne,us