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CITY OF BLAIR - MISCELLANEOUS BUILDING PERMIT
Permit #�
Date: V-` Approximate Completion Date: r7_36 _10 Site Plan Attached: L -
Estimated Valuation of Project: 1e)00- 00
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! ng/Sid1ng/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
Fee: $75 plus bond
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 p oject if necessary: & ' .Vj C lt�o7l 0/ ' Ila ca U_,
Ll ii 1s be a7j, r/ o-II17 —0 04 / 10_� 6O .
PROJECT INFORMATION:
Job Address:
Legal Description (if applicable)'
//Z10, 110e 29
Owner: 7 A; � Address: 3,-)7i Phone#: q2b)
f—
Contractor:
Address:
Phone #:
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: $ 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.
ignature of Owner/Contractor
Date
For Office Use Only WHEN PROPERLY VALIDATED (BELOW) THIS IS YOUR PERMIT
Date Permit Paid: " I `� ' I Receipt #rc3/c.c�
pproved by t
prod/se Of
FENCE PERMIT SUPPORTING DOCUMENTS
This supporting document includes information dealing with particular zoning
requirements and/or fence permit requirements. It in no way includes ALL particular
zoning items. Also, it is your responsibility to know the City of Blair Zoning Ordinance
Section 1102 requirements that apply to fences, walls and hedges. Please understand
this document is only designed and distributed to aid in your fence permit process. A
copy of the City of Blair Zoning Ordinance is available for your use at the Blair Public
Library or on our website at www.blairnebraska.org.
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
Contractor
6�ja�te
218 South 16th Street • Blair, Nebraska 68008 • 402-426-4191 • Fax 402-426-4195 • E-mail cityofblair@ci,blair,ne.us
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�0.0�0'e undable 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.
&�'oZtract=rlow�nY Contractor/Owner
City of Blair
ate
❑'" CITY OF BLAIR
LOCATION OF INSPECTION•
NAME OF OWNER•
DATE INSPECTION REQUESTED
BUILDING , REPORT
❑ WASHINGTON COUNTY
❑ OT
CONTRACTOR
TIME INSPECTION REQUESTED-
PERMIT NOL--.
TYPE OF INSPECTION REQUESTED:
BUILDING: ❑
❑ CONFERENCE �❑STATUSCHECK
_
FOOTING ❑ DECK
FOOTING ❑ FRAMWG ❑ DRYWALL ❑ FINAL ❑ PARTIAL
COMMENTS:
PASSED
FAILED
�
❑
❑
UTILITIES: ❑
SEWER TAP ❑ SEWER ElSEPTIC ElWATER TAP ElREMOTE ❑ WATER
El
COMMENTS:
PARTIAL SERVICE
PASSED
FAILED
❑
❑
ELECTRICAL: ❑
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑ TEMPORARY
❑
SERVICE
PARTIAL ❑ PRECONNECT
PASSED
FAILED
COMMENTS:
�
❑
❑
MECHANICAL: ❑
ROUGH—IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL' ❑ PARTIAL
COMMENTS:
PASSED
FAILED
❑
❑
PLUMBING: ❑
GROUNDWORK ❑ ROUGH—IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
El
COMMENTS:
PRESSURE TEST
PASSED
FAILED
❑
❑
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
�'
NOTES/REMARKS
�
�' , •"f
INSPECTOR
DATE OF INSPECTION MADE: r 's
TIMF
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON
❑ ;'CITY OF BLAIR
LOCATION OF
BUILDING INSPECTION REPORT
❑ WASHINGTON COUNTY ❑
NAME OF OWNER ilei7i
Cp4 A
CONTRACTOR
DATE INSPECTION REQUESTED TIME INSPECTION REQUESTED:
PERMIT
TYPE OF INSPECTION REQUESTED:
- El CONFERENCE
•, V❑•STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL
PASSED
FAILED
COMMENTS:
❑
❑
UTILITIES: ❑
COMMENTS: ❑
SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑ REMOTE ❑ WATER SERVICE
PARTIAL
PASSED
❑
FAILED
❑
ELECTRICAL: ❑
F1
COMMENTS:
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑TEMPORARY SERVICE ElPRECONNECT
PARTIAL
PASSED
/n
FAILED
❑
MECHANICAL: ❑ ROUGH -IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL
PASSED FAILED
COMMENTS: ❑
PLUMBING: ❑ GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL PASSED FAILED
COMMENTS: ❑ PRESSURE TEST ❑ ❑
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
0
m
BUILDING R
❑ �CTI'Y OF BLAIR ❑ WASHINGTON COUNTY ❑ OTHER
LOCATION OF INSPECTION
NAMEOF OWNER• `L e.-'�
CONTRACTOR -
t7
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
❑
❑
COMMENTS:
UTILITIES: ❑
SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑REMOTE ❑ WATER SERVICE
PASSED
FAILED
❑
PARTIAL
❑
❑
COMMENTS:
ELECTRICAL: ❑
ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑ TEMPORARY SERVICE [:1 PRECONNECT
PASSED
FAILED
❑
PARTIAL
❑
COMMENTS:
MECHANICAL: ❑
ROUGH -IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL
s PASSED
FAILED
F]
❑
COMMENTS:
PLUMBING: ❑
GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
PASSED
FAILED
El
PRESSURE TEST
❑
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
INSPECTOR
DATE OF INSPECTION MADE:IV
FAXED OPPD\BURT REA TO CONNECT SERVICE:
TIME:
INSPECTION REPORT
❑';: CITY OF BLAIR ❑ WASHINGTON COUNTY ❑ OTHER
LOCATION OF INSPECTION: 3
s �
NAME OF OWNER -
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
INSPECTOR: DATE OF INSPECTION MADE: - "d-' TIMF €"',� "
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON B
r E'
e
DATE INSPECTION REQUESTED_ TIME INSPECTION REQUESTED- PERMIT NO.• ` C
TYPE OF INSPECTION REQUESTED: ❑ CONFERENCE
❑ STATUS CHECK
BUILDING: ❑
FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL El'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
❑
❑
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: - "d-' TIMF €"',� "
FAXED OPPD\BURT REA TO CONNECT SERVICE: ON B