BP13403—)t C', 610 l a
CITY OF BLAIR - MISCELLA�OUS BUILDING PERMIT
Q ••. gPam „ Permit#
Date: /y Approximate Completion Date: E Site Plan Attached:
Estimated Valuation of Project: f YS
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
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:
PROJECT INFORMATION:
Job Address: d 2
Fee: $75 plus bond
Legal Description (if applicable) ,Re -��-®° ° ��V
.2 z/A Ca.
Owner: y0- �- Address:
Contractor:
Phone #: ) 7 " "S SZ
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 $
Original valuation of $100,000 - $500,000 $300.00 $
Original valuation of $500,000 or more $400.00 $
Issuance Fee:
Deposit:
$ 25.00
$ 50.00
Total Renewal Remit Fee = Permit Fee + Deposit + Issuance Fee $
Separate permits are required for electrical, plumbing, hearting, ventilating and air conditioning, and septic
systems. By my signature below, 1 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.
Signature f Owner /Contractor Date
For Office Use Only WHEN PROPERLY VALIDATED (BELOW) THIS IS YOUR PERMIT
Date Permit Paid: - A - 16 Receipt # � t y'�� Approved by:
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LOCATION OF INSPECTION:
• � , .
❑ WASHINGTON COUNTY
❑ OTHER_
r .
4 !
NAME OF OWNER J 2 .e 4r_ t € ..
CONTRACTO
DATE INSPECTION REQUESTED d ,° F TIME INSPECTION REQUESTED f .' PERMIT NO tt°
TYPE OF INSPECT REQUESTED _ _ _ ❑ CONFEREN
❑ STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL - ❑-' AL ❑ PARTIAL
PASSED
FAILED
COMMENTS
` 1 vc
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 y �
Wry PASSED
FAILED
COMMENTS:
PLUMBING: ❑
GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS i n / r + .R i _ J n A //� 64 e-4 6-k-,(
INSPECTO � DATE OF INSPECTION MADE: TIM
FAXED OPPD \BURT REA TO CONNECT SERVICE: 0 N BY