BPM2005CAICAL PERMIT APPLICATION
Jurisdiction of City of Blair, Nebraska
218 South 16 Street
Blair, Nebraska 68008
Fax (402) 426 -4195 M 2005
(402) 426 -4191
Application Date: Permit Fee: $
7 1- /fib /' ° 1,6 J Ila /7 el- .21d A4 .
Job Address
� (�
Owner Mail Ad ess Zip Phone
1.
Contractor Mail Addres Z Zip Phone
2.
3. Class of Work: O COMMERCIAL �12 ESID TIAL O New O Addition O Alteration O Repair placement
Describe Work:
MECHANI AL PERMIT FEES
Heat Pump Tons
Central A/C Tons
Furnace /Heat Pump /Air Conditioner (Per Unit) X
Furnace 0 O � � 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 (trse BTU Chart to left) ....................
Appliance Vent/Fans ........................$10.00
Notice
Duct System ......... .........................$15.00
I hereby certify that I have read and examined this
application and know the same to be true and correct. All
Gas /Air Outlets 5 x $6.00
provisions of laws and ordinances governing this type of
.................First
work will be complied with whether specified herein or
not. The granting of a permit does not presume to give
.........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 of Contractor or Authorized Agent
06
Permit Issuance Fee . .........................$25.00
Total
Current License on File es O No O N/A
Date
Comment:��
WHEN PROPERLY VALIDATED (1N THIS SPACE) lHVS 1S YUUK FhF M11
Approved By: 0
Rev. 2008 -10