AC-2010-00057_0001.tif CITY OF BLAIR - APPLICATION FOR BUILDING PERMIT
Permit# '
gPromisae a e � s
Date: 7 2- Approximate Completion Date:
Site Plan Attached: REScheck Attached: Complete Plans Attached
Application for Residential Commercial /Industrial
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
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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
Addit ,lonal Description o project if necessary: aL w C -i d C' ' f
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Project Information
Job Address:
Legal Description (if applicable)
Owner: Address: 17 Phone #:
Contractor
ontractor a1 Phone #:
r
� Cell #:
Address: ' " e7
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
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189 days or is not c eted within two (2) years of date of issue.
Signature of Owner /Contractor e
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.
Signature of Owner /Contractor Date
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