SD-2010-00015.tif I
CITY OF BLAIR — APPLICATION FOR BUILDING PERMIT
b r Permit #
Date: Approximate Completion Date: Q
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
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
Additional Description of project if necessary: �. q � �'��� ( of
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Project Information
Job Address:
Legal Description (if applicable)
Owner x � � v\ (Cr-,s K C Address: Phone #: 0
Contractor: Phone #:
Address: Cell #:
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
"� con ction covered by this permit application shall not be commenced until I have received a copy of a permit signed by the Building
Inspect I hereby agree to perform the proposed work in accordance with the specifications set forth above and in accordance with the
/ codes /or 'nances of the City of Blair and the State of Nebraska. I understand that this permit is void if work is not commenced within
180 d Anature i ot co ple ed within two (2) years of a of issue.
Owner /Contrac tor Dat
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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BUILDING PERMIT SUPPORTING DOCUMENTS
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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.
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I have read the above disclosure and accept this building permit documentation on my j
own behalf assuming full responsibility as the owner /contractor for this project.
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caner/ ccupant Contractor
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City of Blair D to
218 South 16th Street • Blair, Nebraska 68008 • 402 - 426 -4191 • Fax 402 - 426 -4195 E -mail cityofblair @ci,blair,ne,us
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BUILDING PERMIT DEPOSIT AGREEMENT
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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,
add.' ' _ % cessory building valued under $10,000.
A $50.0ndable d eposit is being collected for all misc. permits.
The City reserves the right to not refund this deposit if any of the following
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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
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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.
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o ractor /Owner Contractor /Owner
City of Blair
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