PL-2010-00076.tif i
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CITY OF BLAIR
218 S. 16TH STREET
BLAIR, NEBRASKA 68008
B Permit Application (402)426- 4191 -Phone
PL- 2o�0 ®U76 �,d (402)426- 4195 -FAX
A 'O�,r se of a www.blairnebraska.org
08/26/2010 bpeterse PLUMBING Commercial August 26,
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LOCATIONOFIMPROVEMENT: TL'S 198-18-11, Blair, NE 68008
ARCHITECT: GENERAL
SELF
x OvVNER: Jason Kubie CONTRACTOR: SEL Self
10263 County P29 Rd Blair, NE 68008
Blair, NE 68008
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NATURE OF WORK PROPOSED USE
Misc. Permit Secondary
PROJECT NAME PERMIT EXPIRES 02/2212011
13427 ESTIMATED COMPLETION DATE 2010 -08 -26
DESCRIPTION OF WORK
One bathroom, floor drain
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DEPOSIT PAID BY: SITE PLAN SUBMITTED: NA
Contractor REScheck/COMcheckSUBMITTED: NA
DEPOSIT HELD: BUILDING PLANS SUBMITTED: NA
N/A
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1. No work will be started before a permit is ISSUED AND POSTED.
2. For commercial permits, a set of plans for this project must be submitted to the Nebraska State Fire Marshal's Office for review.
3. Separate permits are required for electrical, plumbing, heating, ventilating and air conditioning, and septic system.
4. The undersigned owner or agent understands and acknowledges this building permit application does not constitute issuance of
this building permit. It is further understood that construction covered by this permit application shall not be commenced until a
copy of a permit signed by the Building Inspector is issued.
5. The undersigned owner or agent agrees 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. Any omission of or misrepresentation of
fact with or without the intention of the undersigned or any alteration or change from this application without approval of the
13 ing Official, sha I con itute sufficient ground for the revocation of any permit issued which was based on the approval of this
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ppli ation.
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Signat re of Applicant Date
C1', YL Of F)tAIQ-
wise of a
HOMEOWNER VERIFICATION FOR PLUMBING AND /OR
MECHANICAL PERMITS
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states the following:
Print your full name on line above:
1. I am the owner of the single family dwelling for which I am applying for a
plumbing and/or mechanical permit.
Address: - 7 - Z
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2. I am applying for a plumbing and /or mechanical permit for a single family
dwelling and it is or will be my principal residence.
3. I will install and connect the plumbing and /or mechanical by myself, without
compensation or pay from or to, any other person.
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4. I have sufficient knowledge of the 2006 International Code requirements to make
an electrically safe and mechanically secure installation, which will meet the
minimum standards referenced in the 2006 International Code.
5. I am aware of all inspections required prior to a final.
6. I will call twenty -four (24) hours in advance for an inspection. I am also aware
that it is not the inspector's job or duty to be my instructor in plumbing and/or
mechanical.
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7. I am aware that violation of the code makes it a Class 1 misdemeanor to make a
false statement on a request for inspection.
8. By szg ing this form I am stati g the above information is true an correct.
Home o plicant Signature Date
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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