BP13385CITY OF BLAIR — APPLICATION FOR BUILDING PERMIT
o -
APom„a Permit #
Date: L (L '[e Approximate Completion Date:
Site Plan Attached: Y REScheck Attached: Complete Plans Attached
Application for: Residential
New Construction
Move -on: Home
n.71 I -
Commercial/Industrial
Manufactured Home I Modular.
Accessory Building Other
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 pian required)
Other
Utilities: Public Water: Yes No Private Well
If yes, responsible entity: Blair OPPD Line Kennard
Agreement needed: Date Agreement Received:
Public Sewer: Yes No Septic Drawing Provided:
If yes, responsible entity: Blair Kennard
County Road Permit Required: Yes No Submitted: Yes No No
Additional Description of project if necessary:
Project Information:
Job Address: ke�411 Se / S� 3T4.
Legal Description (if applicable) 99&5 2
Owner: /C6�(�G� Address: Phone#:
Contractor: _ / � 17:X"ma)0Ja11) Phone #:
Address: /4!-7/ 1�1-
Cell #:
fiv
Separate permits are regal ed 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 i n completed within two (2 years,9f date of issue.
ZO 4LO
S" ature of Owner/Contractor Date
For Building Permits other than One & Two Family Residential Structures:
'I hereby a krL j dge and agree that I have/will submit a set of plans for this project to the Nebraska State Fire Marshal's Office for
view o1
�.2? 11 OC
�gnature of Owner/Contractor Date
ZONING REVIEW:
Zoning/Flood Plain/Utilities:
Current Zoning: Conditional Use Permit Required: Yes No
State Fire Marshal Required: Yes
Minimum Setbacks: Front
Lot Square Footage:
Length x Width:
D r i vewa vs /S i d ewa I ks:
Date CUP Approved:
No Variance Required: Yes
Second Front Side Side
Lot Coverage %
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 requirements:
BUILDING INSPECTOR REVIEW:
_ No
Rear
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
Occur)ancv 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 131)
Driveway Grade: 20% grade or less? Yes No
(Dale will review new residential construction. AI 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 Multiplied by 0.006 =
Issuance Fee:
$ 25.00
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $
RAI:W - IVGYY VVIVJ 1 nuV I IVIY I HUU1 I IVIVJ / nGY1VUGLJ:
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 Erectin&Awnings and Decks/Handicap Ramps: sq/ft area X $25 (Minimum
valuation of $2000)
Construction valuation computation:
Finished sq/ft area 0 X $
r
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 $
Issuance Fee: $ 25.00 =1905W'"
Total Permit Fee = Deposit + Permit Fee + Issuance Fee $ 00
Additional Comments:
Approved by: Date: —�7 —1
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
CITY OF BLAIR, NEBRASKA
Phone 402-426-4191
RECEIVED OR
ADDRESS id
CITY, STATE, ZIP CODE
-f
THANK YOU KEEPTHIS COPY FOR YOUR RECORDS.
NO
RECEIVED BY
Pounds Printing, Bien, NE 68008
rvine
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 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.
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
%i liii�1i1
Date
Contractor/Owner
City of Blair
OAb
"/se ofq'���
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.
Owner/Occupant
City of Blair
( - - L\, __L4 - d 2- /2 � � �__
Contractor
1 Joor -Zoite
Date
218 South 16th Street • Blair, Nebraska 68008 • 402-426-4191 • Fax 402-426-4195 • E-mail cityofblair@d.blalr.ne.us
Li ❑
IpANCY GRANTED
DATE OF INSPECTION MADE:
0 CONNECT SERVICE:
�q ( d
�. 4 /
®�_ i�
-1� � _ "r.
_ "--ye (�
:. � y
4,`
_4
�w_
INA
Wei
■
6m 71
— —4
dz
i !"
« \ `om -
\_ . Ila w ..
d y
�
❑s�CITY OF BLAIR
I: /I'll 11111110 i 1
, , 0,
❑ WASHINGTON COUNTY ❑
LOCATION OF INSPECTION7 A'
NAME OF OWNERCONTRACTOR-
r
DATE INSPECTION REQUESTED TIME INSPECTION REQUESTED �' _' . PERMIT NO
TYPE OF INSPECTION REQUESTED: ❑ CONFERENCE ❑ STATUS CHECK
BUILDING ❑' FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL PARTIAL
PASSED
FAILED
J f
COMMENTS `4. c
❑
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 v
PASSED
FAILED
❑
❑
COMMENTS:
PLUMBING: ❑ GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED El PARTIAL
PASSED
FAILED
❑ PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
,m \ / l / V - K --t ^_J/
�` m
INSPECTOR ` moi. DATE OF INSPECTION MADE: 72-C.3-(% TIME- _
FAXED OPPD\BURT REA TO CONNECT SERVICE:
❑ ..CITY OF BLAIR
LOCATION OF INSPECTION:
BUILDING REPORT
❑ WASHINGTON COUNTY ❑
P •
r
NAME OF OWNER: 1 �'°. 4 CONTRACTOR' 4 ,
DATE INSPECTION REQUESTED- TIME INSPECTION REQUESTED: ' - `PERMIT NOS` 5r
TYPE OF INSPECTION REQUESTED: elIla ❑ CONFERENCE ❑ STATUS CHECK
BUILDING: FOOTING ElDECK FOOTING ElFRAMING ElDRYWALL ❑ FINAL ElPARTIAL � PASSED FAILED
COMMENTS C7 Q ❑
UTILITIES:
❑ SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑ REMOTE ❑ WATER SERVICE
❑ PARTIAL
PASSED FAILED
❑ ❑
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
El
❑
COMMENTS:
PLUMBING: ❑GROUNDWORK
❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
PASSED
FAILED
❑
PRESSURE TEST
❑
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
INSPECTOR: DATE OF INSPECTION MADE: "� `� TIME•
FAXED OPPD\BURT REA
TO CONNECT SERVICE:
BY
BUILDING INSPECTIONT
ITY OF BLAIR ❑ WASHINGTON COUNTY ❑ OTHER
3:j ps
LOCATION OF INSPECTION-
NAME
NSPECTION
NAME OF OWNER- ''� ' CONTRACTOR:
DATE INSPECTION REQUESTED- TIME INSPECTION REQUESTED- �I
PERMIT NO -
TYPE OF INSPECTION REQUESTED: ❑ CONFERENCE ❑ STATUS CHECK
BUILDING: ❑:,, FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIALS PASSED FAILED
Pip, - 4A. c,�- Ai vA � ElMENTS
COMfpC!
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:-?—( 9-r ® TIME-
FAXED
IM •
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON BY
COMMENTS:
❑ OCCUPANCY GRANTED D CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS- 544-. tj- — o I oo 6 o
INSPECTOR LDATE OF INSPECTION MADE: TME---(
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON BY
BUILDING INSPECTION REPORT
)<-CITY OF BLAIR
❑ WASHINGTON COUNTY F] OTHER
j
LOCATION OF INSPECTION -
NAME OF OWNER-
CONTRACTOR -
DATE INSPECTION
REQUESTED TIME INSPECTION REQUESTED- PERMIT N
TYPE OF INSPECTION REQUESTED: El CONFERENCE
F1 STATUS CHECK
BUILDING: F -I
FOOTING F] DECKFOOTING [I FRAMING El DRYWALL [_1 FINALPARTIAL
PASSED
FAILED
COMMENTS:
UTILITIES: F -I
SEWER TAP F-1 SEWER [I SEPTIC F1 WATER TAP F-1 REMOTE [_1 WATER SERVICE
PASSED
FAILED
F
PARTIAL
El
El
COMMENTS:
ELECTRICAL: F]
ROUGH iNFI FINAL F] PERMANENT SERVICE F TEMPORARY SERVICE F -I PRECONNECT
PASSED
FAILED
F-1
PARTIAL
El
El
COMMENTS:
MECHANICAL: F]
ROUGH -IN F A/C F FURNACE El RADIANT HEAT El FINAL F1 PARTIAL
PASSED
FAILED
COMMENTS:
PLUMBING: F
GROUNDWORK F -I ROUGH -IN F1 FINAL F -I WATER METER INSTALLED [I PARTIAL
PASSED
FAILED
F-1
PRESSURE TEST
El
El
COMMENTS:
❑ OCCUPANCY GRANTED D CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS- 544-. tj- — o I oo 6 o
INSPECTOR LDATE OF INSPECTION MADE: TME---(
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON BY