BP13470Site Plan Attached: " REScheck Attached: Complete Plans Attached
Application for Residential Commercal/Indu_strial
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 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 _
Additional Description of project if necessary:
_ Private Well
Blair OPPD Line Kennard
Date Agreement Received:
® Septic Drawing Provided:
Blair Kennard
® Submitted: Yes No
�, It
4C` /V ' a
Project Information
Job Address:
//
Legal Description (if applicable)
Own Address: �/ '?, ' W") / Phone #:
/ \
Phone #:
Cell #:
Email Address for Contractor:
Separate permits are required for electrical, plumbing, heating, 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 wi hin two (2) years of date of issue.
t=
Sigry' tureof6w' ner/ ontractor 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.
Contractor:
( V
Address: //'/')
Signature of Owner /Contractor
Date
ZONING REVIEW:
Zoning /Flood Plain /Utilities:
Driveways /Sidewalks:
Sidewalk required: Yes No Sidewalk Waiver: Yes No
Date Waiver Approved:
Preexisting Garage reqLiires riveway to be less than 3' from property line:
Approved by:
Flood Plain: Yes No
If yes, specify special require s•
BUILDING INSPECTOR REVIEW:
Number of Stories
One Two Three Four
lype of Residential Structure:
Ranch Two Story Split Entry
Rooms Bedrooms Bathrooms
Yes
>Four High Rise ( >75 ft)
Raised Ranch Other
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:
Basement: (Unfinished)
Garage: 2 bay
Detached Garage:
Addition:
Porch: Front
Deck that affect setbacks:
Occuaancv Classification:
Rear
Rear
Remodel:
Side
4 bay 5+ bay
Front Side
Assembly, theaters, with stage
Assembly, nightclubs
Assembly, churches
Assembly, general, community ha
Business Educational
Factory and industrial, low hazard
(Finished)
3 bay—
Pole Barn:
Assembly, theater, without stage
Assembly, restaurants, bars, banquet halls
Assembly, arenas
Ils, libraries, museums
Factory and industrial, moderate hazard
High Hazard, explosives
Third Level
(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 1313 NFPA 1.3D
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:
I'- I "M a rZT S R n M Me,
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 $
11,1:6111114, k i T-11 M i+ 1� 1 y a ll e l O R I Z
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
Garage sq/ft area
Total Valuation:
X $29
X $25
Total Valuation Multiplied by 0.006 =
Issuance Fee:
$
$ 25.00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $
iLdML — ivcav %,viva 1 nU , i ivw / MIJUI I IVINO / nr-1VwuCL.7:
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 $2000)
Construction valuation computation ry
Finished
sq/ft area r
x$
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 $ 9 U) . Vo
Issuance. F ee: $ 25.00 1 ! i • 0
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $ 00
Additional Comments:
Approved by: Date: I
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
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INSPECTO
DATE OF INSPECTION MADE: " r® TIMF —
FAXED OPPDTURT REA TO CONNECT SERVICE: ON BY
'BUILDING INSPEC
Q
0-1 CITY OF BLAIR ❑
❑ WASHINGTON COUNTY ❑ OTHE
LOCATION OF INSPECTION
NAME OF OWNER P +
+_ f ° _ a CONTRACTO • >`
4
.v'
DATE INSPECTION REQUESTED TIME INSPECTION REQUESTED PERMIT N
NO
TYPE OF INSPECTI REQUEST ❑ CONFER ❑
❑ STATUS C ?'
BUILDING: r
OOTING ` DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL P
P SSED F
FAILED
r ❑
❑
COMMENTS:
UTILITIES: ❑ S
SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑ REMOTE ❑ WATER SERVICE P
PASSED F
FAILED
❑ P
PARTIAL ❑
❑ ❑
❑
COMMENTS:
ELECTRICAL: ❑ R
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑ TEMPORARY SERVICE ❑ PRECONNECT P
PASSED F
FAILED
❑ P
PARTIAL ❑
❑ ❑
❑
CO MMENTS
MECHANICAL: ❑ T
-IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL P
PASSED F
FAILED '
❑ ❑
❑
COMMENTS:
PLUMBING: �❑ G
GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL P
PASSED F
FAILED
❑ P
PRESSURE TEST ❑
❑ ❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS-
DATE OF INSPECTION MADE: " r® TIMF —
FAXED OPPDTURT REA TO CONNECT SERVICE: ON BY
INSPECTO DATE OF INSPECTION MADE: ❑ -
FAXED OPPD\BURT REA TO CONNECT SERVICE: 0 N BY
BBUILDING
❑ u CITY OF BLAIR
❑ WASHINGTON COUNTY ❑ OTHE
LOCATION OF INSPECTION:
.,
NAME OF OWNER./
�:�� .' CONTRACTO
S °
DATE INSPECTION REQUESTED
TIME INSPECTION REQUESTED PERMIT
N0
TYPE OF INSPECTION REQUESTED: ❑ CONFEREN
❑ STATUS CHECK
BUILDING: ❑'. FOOTING g DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL
PASSED
FAILED
❑
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
❑
❑
CO MMENTS:
PLUMBING: ❑
GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS
LL n
INSPECTO DATE OF INSPECTION MADE: ❑ -
FAXED OPPD\BURT REA TO CONNECT SERVICE: 0 N BY