BP13473CITY OF BLAIR MISCELLANEOUS BUILDING PERMIT
^ AromsaoEa Permit # 1 F%
Date: a Approximate Completion Date:"f Site Plan Attached:
Estimated Valuation of Project: 1060 °c'
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)
Roofing/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 Fee: $75 plus bond
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:
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Job Address: /,-<,&7 r c�L1c.:�°��� ;,� / ` 'g��,q /A
Legal Description (if applicable) e /' b' f //�Lz
Owner.( -:X/
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Address: l C "% 61"�'
Phone#:
Contractor: (91 Jf
<s �,-Phone #: qZ"
Address: ✓/ Cell #:
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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: $ 25.00
Deposit: $ 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, 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 within two (2) years of date of issue.
b� L 'zA / La
Signature of Owner/Contractor Date
For Office Use Only WHEN PROPERLY VALIDATE THIS IS YOUR PERMIT
Date Permit Paid: (< /0 Receipt # q"7 Approved bye—
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CITY OF BLAIR, NEBRASKA
Phone 402-426-4191
RECEIVED OP:
ADDRESS
CITY, STATE, ZIP CODE
Pounds Printing, Blair, NE 68008
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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 efundable 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.
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.
Con or/Own Q C
ate
Contractor/Owner
City of Blair
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❑er-CITY OF BLAIR
LOCATION OF INSPECTION:
i U I'll I,, I ,
❑ WASHINGTON COUNTY
NAME OF OWNER s .' :' ., s .. °r, ,. -y a _L ( ,;1µ J
DATE INSPECTION REQUESTED `' t� C°
❑m
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1 #
CONTRACTOR- L u `c
TIME INSPECTION REQUESTED I� Z" PERMIT NO' ° fi
TYPE OF INSPECTION REQUESTED:
❑ CONFERENCE
❑ STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING ❑
FRAMING ❑ DRYWALL ❑ FINAL Fl PARTIAL
PASSED
FAILED
COMMENTS:
s �''rf ¢'')�'
Cf r..` ? ' ",r.. {
❑
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 F1 WATER METER INSTALLED ❑ PARTIAL
m PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
INSPECTOR- DATE OF INSPECTION MADE: �� •- a TWE--
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON BY
❑ 'CITY OF BLAIR
LOCATION OF INSPECTION:
NAME OF
I oll" I " I IM -1 u plej 11
F-1 WASHINGTON COUNTY F-1 OTHER
DATE INSPECTION REQUESTED- TIME INSPECTION REQUESTED PERMIT No
TYPE OF INSPECTION REQUESTED: F] CONFERENCE
Fl STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING F-1 FRAMING ❑ DRYWALL E:l FINAL Fl PARTIAL
PASSED
FAILED
COMMENTS.
UTILITIES: F-1
SEWER TAP F-1 SEWER F1 SEPTIC R WATER TAP F1 REMOTE [-] WATER SERVICE
PASSED
FAILED
F1
PARTIAL
COMMENTS:
ELECTRICAL: Fl
ROUGH IN R FINAL Fl PERMANENT SERVICE 0 TEMPORARY SERVICE R PRECONNECT
PASSED
FAILED
F1
PARTIAL
❑
El
COMMENTS:
MECHANICAL: F-1
ROUGH -IN F-1 A/C F1 FURNACE 0 RADIANT HEAT El FINAL F1 PARTIAL
PASSED
FAILED
F-1
F1
COMMENTS:
PLUMBING: ❑
GROUNDWORK El ROUGH -IN [:1 FINAL 0 WATER METER INSTALLED El PARTIAL
PASSED
FAILED
❑
PRESSURE TEST
COMMENTS:
R OCCUPANCY GRANTED [I CONDITIONAL OCCUPANCY GRANTED
INSPECTOR: DATE OF INSPECTION MADE: 6--73n e TIME -
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON BY