BP13392x CITY OF BLAIR - APPLICATION FOR BUILDING PERMIT
«j5e Permit #
Date: % - Approximate Completion Date:
Site Plan Attached: REScheck Attached: Complete Plans 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 No
Sign Erecting, Awnings Decks/Handicap Ramps (plot pian 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 _
Additional Description of project if pecessary:
Project Information:
Job Address:
Legal. Description (if applicable)
Owner: T C- ,
Contractor:
Address:
_ Private Well
Blair OPPD Line Kennard
Date Agreement Received:
Septic Drawing Provided:
Blair Kennard
Submitted: Yes No
Address:
Email Address for Contractor: 1V/14
ZZO A) iG
Phone#:
Phone #:
Cell #:
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
co dinances 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 is not coFewltwo (2) years of date of issue.
Si nature of 0 ner/Contractor 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:
ZoningZFlood Plain UMiles:
Current Zoning: Conditional Use Permit Required: Yes No
Date CUP pproved:
State Fire Marshal Required: Yes No Variance Required: Yes No
Minimum Setbacks: FrontSecond Front Side Side Rear
Lot Square Footage:
Length x Width: Lot Coverage %
Driveways/Sidewalks:
Sidewalk required: Yes No Sidewalk Waiver: Yes No
Date Waiver Approved:
Preexisting Garage requires-dri e y to be less than 3' from property line:
Approved by:
Flood Plain: Yes No
If yes, specify special re rements:
BUILDING INSPECTOR REVIEW:
Yes
Number of Stories
One Two Three Four >Four High Rise (>75 ft)
Dpe 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
Square 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
Occupangy 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, 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. At 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 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
Issuance Fee:
Multiplied by 0.006 =
$ 25.00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $
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 followl=.
Accesso!y 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
$2,001 TO $25,000........................................................ $70
$25,001 TO $50,000......................................................$370
$50,001 TO $100,000......................................................$620
$100,001 TO $500,000......................................................$970
$500,001 TO$1,000,000.................................................. $2,970
$1,000,001 AND OVER .................................................. $4,970
+ $3
+ $13
+$10
+ $7
+ $5
+ $4
+ $3
per additional $100
per additional $1,000
per additional $1,000
per additional $1,000
per additional $1,000
per additional $1,000
per additional $1,000
Permit Fee calculated from chart above
$ ✓d
Issuance Fee:
$ 25.00 -: q.:�i
Total Permit Fee = Deposit + Permit Fee + Issuance Fee
$ `� ` 00
Additional Comments:
Approved by: Date:
d`
` > `�®a_ 10
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
Phone 402-426-4191
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 r fundable deposit is being collected for any residential remodel,
(addition gr ccessory 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/Own r Contractor/Owner
City of Blair
Date
FILE COPY
IT NO.
_pERW
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ADDRESQ , 53
[—icc
RECEIVED CITY OF BLAIR APPROVED
APPRI
Application for Building Permit FBUILDIN�G.
P I tl i'�j I J� ,
MAR 1 z Zola PLANN114G 3.11 All
CITY OF BLAIRPUBLIC WORKS
NEBRASKA PLOT PLAN
FIRE DEPT
05J Date Ue T -R C
Address C�
r W'? -LT Z Block __L_ Addition
Legal Description: Lot J
Please show all measurements of existing and contemplated structures,
also show distances between'structures, etc., and property lines.
AP'IMAL AS A RESULT OF AN IIS SPFGT10,P
Is this a corner lot?' SHALL NOT BE CONSTRUED TO BE AN APPROVAL
OF A VIOLATION OF THE PROVISIONS OF THE
CODE OR OF OTHER ORDINANCES OF THIS
JURISDICTION.
Line
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Inu-L%;cL g. � Lw— —
417'W'*
Street
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4-14 1
CA
!(o"
Application Date
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
Fax (402) 426-4195
(402) 426-4191
Permit Fee: $ Cx l - ey
Job Address
Owner / Mail Address Zip ,1 Phone _
�9
1. av / -Ll %
Contractor Mail Address Zip Phone
2. 4411-
3. Class of Worlt. O NEW RESIDENTIAL 13 NEW COMMERCIAL REMODELING/ADDITIONS O UPGRADE SERVICE
4escribe Work:�l L�c G GC fes/ ! ^�4,m G%i' (L''J1(i c 6 L.%/n-
5.Current License on Fie 0" 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
Fire Alarm System............ .......$15.00
201-300 Amp Fee .......................$55.00
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
901-1000 Amp.........................$195.00
Amp Fee
IF OVER 1000 Amp
1St 1000 Amp Fee..................$195.00
Amp Fee + Circuit Total
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
Other: (alterations, additions and modifications)
work will be complied with whether specified herein or
not. The granting of a permit does not presume to give
authority to violate or cancel the provisions of any other
Receptacles/Switches/Lighting Fixtures (I 10 volt onl )
# of Apparatus .......... / x $1.00 tJ
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
Signature o ntra or or Authorized Agent
Permit Issuance Fee... ..$25.00
Total
Date
Comment:
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Approved By:
zl.
Rev. 2008-10
MECHANICAL PERMIT APPLICATION
Application Date: �.
Jurisdiction of City of Blair, Nebraska
218 South 16th Street
Blair, Nebraska 68008
Fax (402) 426-4195
(402) 426-4191
M 11965
� DJ
Permit Fee: $ CZ
Job Address
Owner - / Mail Address Zip Phone
1. la'l f C L1 Lr r�`
146
Contractor Mail Address Zip Phone
2. _
3. Class of Work: O COMMERCIAL CI<RESIDENTIAL O Newddition O Alteration O Repair O Replacement
Describe Work:
4.
MECHANICAL PERMIT FEES
Heat Pump Tons
Central A/C Tons
Fumace/Heat Pump/Air Conditioner (Per Unit)
Furnace BTU/H
Up to and including 100,000 BTU / 3Ton............................$15.00
# of Units A/C
Furnace/Heat Pump/Air Conditioner (Per Unit)
Furnace
Over 100,000 BTU / 3 Ton.............................................$25.00
Completion Date:
Refrigeration Units/Coolers/Lines/Compressor — Commercial
(New or Replacement) (Per Unit)
Boiler Chart
BTUFee
..............................................................................$15.00
Up to 100,000 ................................$15.00
100,000-500,000 .............................. $30.00
500,000-1,000,000 ........................... $40.00
1,000,000-1,750,000 ........................ $ 60.00
Over 1,750,000 ..............................$100.00
Boiler (use BTU Chart to left)....................
Appliance Vent/Fans ........................$10.00
Notice
I hereby certify that I have read and examined this
Duct System......... .............$15.00
""'""' °
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of
Gas/Air Outlets.................First 5 x $6.00
work will be complied with whether specified herein or
/ r
not. The granting of a permit does not presume to give
1 ViM.... Additional x $1.00
authority to violate or cancel the provisions of any other
state or local law regulating construction or the
Radiant Heat Systems/Gas/Water
performance of construction.
>
Piping System......... $50.00
Modular Home ............................... $50.00
Signature ol C ntra or or Authorized Agent
Permit Issuance Fee .......................... $25.00 r�
Total(
Current License on File 4'Yes O No O N/A
Date
Comment:
WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT
Approved By: , ,
Rev. 2008-10
PLUMBING PERMIT APPLICATION
Jurisdiction of City of tBlair, Nebraska
218 South 16 Street
Blair, Nebraska 68008
Fax (402) 426-4195 P 2093
/ (402) 426-4191
Application Date:" / l Permit Fee: $ Vii° U
Job Address
d -5_J4,
Owner ' � Mail Address Zip Phone
'J
GZL�aLil
1. 7 c F✓� tho
Contractor, Mail Address Zip Phone
2.
3. Class of Wo t: O COMMERCIAL-�'f�ESIDENTIAL O New-CAddition O Alteration O Repair O Replacement
Describe Work: /
4.
PLUMBING PERMIT FEES
Comments:
Modular Home ......................$50.00
Type of Fixture No.
Kitchen .............................. $12.00 x
Bath..... Residential/Single Stall $12.00 x
....................Multi -Stall $25.00 x
Rough -In Bath ........................ $8.00 x
Additional Sinks.....................$6.00 x
Slop Sink/Laundry Tray/Drain ..... $6.00 x 1 ob
Water Heater .........................$10.00x-
10.00xNotice
Notice
Outside Water Faucet...................$6.00 x
I hereby certify that I have read and examined this
Drinking Fountain ........................$6.00 x
application and know the same to be true and correct. All
provisions of laws and ordinances governing this type of
work will be complied with whether specified herein or
Backflow/Grease Trap$15.00
not. The granting of a permit does not presume to give
authority to violate or cancel the provisions of any other
Water Service .......................$15.00
state or local law regulating construction or the
Sewer
performance of construction.
.................................$15.00
Groundwork .........................$15.00
Septic Tank & Laterals............ $15.00
Lawn Sprinkler System ............ $10.00
Sprinkler System (Commercial).. 30.00
Gas/Water Piping System
' .,
(Commercial)...... ..................$50.00
Signature of� ntra dor or Authorized Agent
Permit Issuance Fee.................$25.00 06
Total 06
Current License on File des O No O N/A
Date
Comment:
WHEN FROVERL Y V ALIUA I L) (11N 1 rill 1 r113 13 r v urs., rr,lxivii i
Approved By:
Rev. 2008-10
of G�
CITY OF I)LAIQ
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
own behalf assuming full responsibility as the owner/contractor for this project.
wrier Occup fit Contractor
City of Blair ate
218 South 16th Street • Blair, Nebraska 68008 • 402-426-4191 • Fax 402-426-4195 • E-mail cityofblair@ci,blaicne,us
my
W_
[ CITY OF BLAIR
❑ WASHINGTON COUNTY
LOCATION OF INSPECTION -
NAME OF OWNER• e
❑ OTHER_
DATE INSPECTION REQUESTED- ° - TIME INSPECTION
PERMIT N0 -
TYPE OF INSPECTION REQUESTED: ❑ CONFERENCE
❑ STATUS CHECK
BUILDING: ,❑
FOOTING ❑ DECKFOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL
PASSED
FAILED
•
G 3 i -,
❑
COMMENTS:
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:
MECHANICAL: ❑
ROUGH—IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL
PASSED
FAILED
❑
❑
COMMENTS:
PLUMBING: ❑
GROUNDWORK ❑ ROUGH—IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
INSPECTOR - DATE OF INSPECTION MADE:
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON
I elm I m up[my
CITY OF BLAIR F1 WASHINGTON COUNTY ElC
LOCATION OF INSPECTION -
NAME OF OWNER- 7 J CONTRACTC
COMMENTS:
F -I OCCUPANCY GRANTED [_1 CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
INSPECTOR- WY41-
DATE OF INSPECTION MADE: TIME
FAXED OPPD\BURT REA TO CONNECT SERVICE:
BY
DATE INSPECTION REQUESTED:
TIME INSPECTION REQUESTED- PERMIT NO -
TYPE OF INSPECTION REQUESTED:
EICONFERENCE
E] STATUS CHECK
BUILDING: F1
FOOTING F -I DECK FOOTING E:l
FRAMING ❑ DRYWALL F -I FINAL F] PARTIAL
PASSED
FAILED
El
COMMENTS:
UTILITIES: F1
SEWER TAP F] SEWER F1 SEPTIC ❑ WATER TAP F-1 REMOTE F-1 WATER SERVICE
PASSED
FAILED
F]
PARTIAL
El
E]
COMMENTS:
ELECTRICAL: ❑
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE F] TEMPORARY SERVICE F -I PRECONNECT
PASSED
FAILED
F-1
PARTIAL
El
1:1
COMMENTS:
MECHANICAL: R
ROUGH IN El A/C R FURNACE
F] RADIANT HEAT F] FINAL F -I PARTIAL
PASSED
FAILED
F -I
R
COMMENTS:
PLUMBING: F]
GROUNDWORK F-1 ROUGH -IN F]
FINAL El WATER METER INSTALLED F -I PARTIAL
PASSED
FAILED
F-1
PRESSURE TEST
El
0
COMMENTS:
F -I OCCUPANCY GRANTED [_1 CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
INSPECTOR- WY41-
DATE OF INSPECTION MADE: TIME
FAXED OPPD\BURT REA TO CONNECT SERVICE:
BY
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