PL-2010-00131.tif i
CITY OF BLAIR
v 218 S. 16TH STREET
BLAIR, NEBRASKA 68008
Building Permit Application (402)426 -4191 -Phone
(402) 426 -4195 - FAX
PL- 2010 -00131 ArO mise Of 0. 00\ www.blairnebraska.org
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09/24/2010 bpeterse PLUMBING Residential September 24, 2010
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LOCATION OF IMPROVEMENT: 10135 Crystal Lake Dr, Blair, NE 68008 -7571
ARCHITECT:
GENERAL SELF
OWNER: Joseph And Debra Wilson CONTRACTOR:
10135 Crystal Lake Dr Blair, NE 68008
BLAIR, NE 68008 -0000
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NATURE OF WORK PROPOSED USE
Misc. Permit Primary Residence
PROJECT NAME PERMIT EXPIRES 03123/2011
10135Crystal LakeDr- 100924 - Plumbing ESTIMATED COMPLETION DATE 2010 -10 -01
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DESCRIPTION OF WORK
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Backflow Preventor for underground potable water lines
DEPOSIT PAID BY: SITE PLAN SUBMITTED: NA
Contractor
REScheck /COMcheck SUBMITTED: NA
DEPOSIT STATUS: BUILDING PLANS SUBMITTED: NA
N/A
1. No work will be started before'a permit is ISSUED AND POSTED.
2. For commercial ermits a set of plans for this project must be submitted to the Nebraska State Fire Marshal's Office for review.
p p p roj
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 unders" n d owner or agent agrees to perform the proposed work in accordance with the specifications set forth above and
in accorda c wi h the codes /ordinances of the City of Blair and the State of Nebraska. Any omission of or misrepresentation of
fact with r it out the intention of the undersigned or any alteration or change from this application without approval of the
Building ffi ial shall constitute sufficient ground for the revocation of any permit issued which was based on the approval of this
applicati
Signature o ka)L Date
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f r o
Ise of a
HOMEOWNER VERIFICATION FOR PLUMBING AND /OR
MECHANICAL PERMITS
states the following:
Print your full e 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:
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.
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.
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 s' g this
Z_ form I am stating the above information is true an correct.
Ho o ner Applicant Signature Date
218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 - 426 -4195 E -mail cityofblair @d,blair.ne,us oPOOa' "