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CITY OF BLAIR - APPLICATION FOR BUILDING PERMIT
gP .om„a o a Permit #
Date: �- % Approximate Completion Date: 1 i - 1 , - . L A l i
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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 owers (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:
Project Information
i
Job Address:
Legal Description (if applicable)
Owner: O l a ddress: ��'� Phone #:
Contractor: c ' >'�' Phone #: ° ��
Address: I ", J Cell #: e f
Email Address for Contractor: L ; /texod , r cL n e-,0 Li al��
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
180 days or is not completed within two (2) years of ate of Issue.
ignature of Owner/ ontractor ate
For Building Permits other than One & Two Family Residential Structures:
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