CN-2013-00543.tif Dee, 20. 2013 4:25PM CITY OF BLAIR (402.426.4191) No, 1971 P. 1
CITYOFBLAIR
218 S. I OTH STREET
BLAIR, NEBRASKA 68008
uilding Permit Application (40 426 -4191 -Phone �
y �+ (402) 426 -4195 - FAX
CN- 2013 -00543 a ui a�a� www.blalrnebrastta.org.
11/99/2013 COM•NEW Commercial December 17, 2013
i LOCATIONOFIMPROVEMENT: 2028 Kellie Dr, Blair, NE 68008
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*} s ,ARCH11ECt.. GENERAL. SELF
1 0 `OMER; Casey's Retail Company CONTRACTOR:
PO Box 3001 Blair, NE 68008
ANKENY.IA 50021 -0000
NATURE OF WORK PROPOSED USE
Now Construction Primary Commercial-
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PROJECT NAME PERMIT EXPIRES 11/19/2015
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2028KBgieDr•131119•New Commercial ESTIMATED COMPLETION DATE 41112014
DESCRIPTION OF WORM
New Casey's gas station and Convenience Store 2 bathrooms and 12 gas pumps.
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DEPOSIT PAID BY: SITE PLAN SUBMITTED: Received
Contractor
REScheck1COMcheck SUBMITTED: Received
DEPOSIT STATUS: BUILDING PLANS SUBMITTED; Received
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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,
S. 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
Building Official, shall constitute sufficient ground for the revocation of any permit issued which was based on the approval of this
applic ion. '
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Signature of Applicant t'l Data
CITY I, NEBRASKA
Phone 402 -426 -4191
RECEIVE F:
ADDRESS
CITY, STATE, ZIP CODE ` R
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THANKYOU K H) OPYFORYOURRECORDS.
NO 344
RECEI BY
Pounds Printing, Blair, NE 60008
CITY OF BLAIR, NEBRASKA
Phone 402 -426 -4191
RECEIVED OF.
ADDRESS
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CITY, STATE, ZIP CODE 1
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THANKYOU KEFPTHIS COPY FOR YOUR RECORDS.
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RECEIVED BY
Pounds Printing, glair, NE 88008
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Dec. 20. 2013 4.26PM CITY OF BLAIR (402-426,4191) No, 1971 P. 3
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BUILDING PERMIT DEPOSIT AGREEMENT
A $500,00 refundable deposit is being collected for any new commercial, new
residential, and any additions, remodels and accessory building valued $10,000 or
greater at the time of your building permit application.
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A $200.00 refundable deposit is being collected for any residential 'remodel,
addition or accessory building valued under $10,000.
A $50,00 refundable deposit Is being collected for all misc. permits.
The City reserves the right to not refund this deposit if any of the following
conditions occur during the construction period:
1) Theft of water service by the plumber, owner or general contractor.
2) All permits have not been obtained.
3) All required inspections have not been obtained.
4) Occupancy occurs prior to a final inspection.
5) The project is completed without a final inspection being done.
6) Storm Water Management Plan inspection not obtained. (If Required)
If any or all of these situations occur during construction, you may forfeit your
deposit.
I hereby agree to the above conditions, and understand that should any or
all of the above situations occur, the building permit deposit SHALL be forfeited or
discounted upon the discretion of the City of Blair, Building and Inspections
Department.
Contr for /Owner - Gontractor /Owner a cowrallu
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City of Blair
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Dec. 20, 2013 4:26PM CITY OF GLAIR (402. 426.4191) No. 1971 P. 4 ! j
CITY Of BLAIQ
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BUILDING PERMIT SUPPORTING DOCUMENTS
This building permit packet includes various items dealing with particular code
requirements and /or building permit requirements. It in no way includes ALL particular
code items. Also, it is your responsibility to know the 2009 International Building
Code requirements that apply to your project. Please understand this packet is only
designed and distributed to aid you in your building permit process. A copy of the !
International Building Code is available for your use of the Blair Public Library.
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I have read the above disclosure and accept this _ building permit documentation - on - my
own behalf assuming full responsibility as the owner /contractor for this project.
Owner /Occupant ontractor
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City of Blair Date
218 South 16th Sheet Blair, Nebraska 68008 • 402.426 -4191 Fox 402-426.4195 • r -moll oityofbtalr @d,btoirne.us