SD-2010-00015 (2).tif s x
CITY OF BLAIR — APPLICATION FOR BUILDING PERMIT bola
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A Promize � o.
Permit #
Date: "` �`1"/ 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 j
Accessory Building: Garage Pole Barn Other
Floor Type: Dirt Concrete Electricity: Yes No
Sign Erecting, Awnings Decks /Handicap Ramps (plot plan required) cam
Satellite Dishes_ /Radio Antenna /Cell Towers (plot plan required) j
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 j
County Road Permit Required: Yes No Submitted: Yes No
Additional Description of project if necessary; w�, Gv ►,LCAC of
A Aa i G t.�14 t•
Project Information
Job Address: 0
Legal Description (if applicable)
Owner: .)yN\ v\ Address: Phone #: 00
Contractor: e. Phone #:
Address: Cell #:
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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 days r is not co le ed within two (2) years of Pa of issue.
--,� nature O f Owner /Contractor Dat
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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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MINE
-- -- _� — 6106
REV JOHN W EMSLIE JR v- eaaoiaoao
MAR_ THA -JEAN EMSLIE
2055 WASHINGTON ST
BLAIRNE 68008 Date
PH 402 426 -1800
Pay to the
Order `of ars o ' � as
maha
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For
1:3040a330
Harland Cl .,k. -_ --
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