SD-2010-00006.tif CITY OF BLAIR — APPLICATION FOR BUILDING PERMIT r�
•APramba °Q Pe rmit #
Date: 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 O WYes Floor Type: Dirt Concrete No
Sign Erecting, Awnings ✓ Decks /Ha s (plot plan required)
Satellite Dishes /Radio Antenna /Cell lot 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 De cription of project if necessary: L0� X �� `l r� `�71/ `�1z4C',�P
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Project Information A
Job Address: / `�
Legal De cription (if applicable)
Own Address: � Phone #•
Contractor: � � l 92
Address: // o c )'�• � ' e- ` y & ` Cell #:
Email Address for Contractor: f A iYMr 211 000 Y CLAan ears . (26In
Separate permits are required for electrical, plumbing, heating, ventilating and air conditioning, and septic systems. By my signature
below, I ac edge this building permit application does not constitute issuance of this building permit. I further agree that
construct! co red by this r R application shall not be commenced until 1 have received a copy of a permit signed by the Building
Inspect I h eby agree to erf m the proposed work in accordance with the specifications set forth above and in accordance with the
codes / ;rdi nces he Ci of lair and the State of Nebraska. I understand that this permit is void if work is not commenced within
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ays r is n omplet d w in two (2) years of date of issue.
tune of Owner Con ractor Date j
For Building Permits other than One & Two Family Residential Structures:
1 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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A a r
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Promis e
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 r ndable deposit is being collected for all misc. permits.
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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. j
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.
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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
Depa�k nt.
ntractor /Owner Contractor /Owner
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City of Blair
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7 Z� 12- c)/ 0
Date