13489_0002.tif 1- CITY OF BLAIR — APPLICATION FOR BUILDING PERMIT
Permit #
Date: y�� "' Approximate Completion Date:
Site Plan Attached: REScheck Attached: Complete Plans Attached ✓
Application for Residential Commercial /Industrial
New Construction r 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 Towers (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
Addit'onal Descripti of project if necessary: - '"
Project Information / / / �1
Job Address: (D a� zJ -.Auti V r '
Legal Description (if applicable �� � Gl'd�
Owner: f TW 1v`�7�? ddress: ��' U Phone #:
L "t Contractor: �T ��`.�/.I�iG�o� a Phone #:
"le Address: / ��h'iGt�Gt /�T `7 Cell #: 8 7 ��3 3Y'. 3
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
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/ordingid9of the city of Blair and the State of Nebraska. I understand that this permit is void if work Is not commenced within
1 0 days is t comp to Ithin two (2) years of date of issue.
Signat a of Owner /Contrac or to
For Building Permits other than One & Two Family Residential Structures:
I 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