CE-2014-00530.tif CITYOFBLAIR
218 S. 16TH STREET
BLAIR, NEBRASKA 68008
Building Permit Application (402) 426 -4191 -Phone
CE -20'� 4 -0053 a'o �, (402) 426 -4195 - FAX
is of a www.blairnebraska.org
06/24/2014 bpeterse CURB -EXC Commercial June 24, 2014
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LOCATION OF IMPROVEMENT: 2028 Kellie St, Blair, NE 68008
ql r ARCHITECT:
'., GENERAL Larry Hackett Construction Inc.
owNER: Hayden Place Development, Llc CONTRACTOR: 21023 430th St
OAKLAND, IA 51560
12049 Co Rd P30
BLAIR, NE 68008 -0000
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NATURE OF WORK STRUCTURE
Sub -Work New Const Primary Commercial- Casey's
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PROJECT NAME PERMIT EXPIRES 06/23/2016
2028KellieDr- 131119 -New Commercial ESTIMATED COMPLETION DATE 6/24/2016
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DESCRIPTION OF WORK
Street cut for sewer.
DEPOSIT PAID BY: SITE PLAN SUBMITTED: NA
Contractor
REScheck /COMcheck SUBMITTED: NA
DEPOSIT STATUS: BUILDING PLANS SUBMITTED: NA
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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.
5. 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
app i ation.
Date
Signature of Applicant
CITY OF BLAIR, NEBRASKA
Phone 402 -426 -4191
RECEIVED OF.
ADDRESS
CITY, STATE, ZIP CODE
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THANKYOU KEEP THIS COPY FOR YOUR RECORDS.
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Pounds Printing. Blair, NE 60008
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CITY Of I)tAIQ
o �ise of a
STREET / UTILITY EXCAVATION PERMIT SUPPORTING FORM
AND DEPOSIT AGREEMENT
This street / utility excavation permit form includes various items dealing with particular
code requirements and /or city requirements. Also, it is your responsibility to know the 2009
International Building Code requirements that apply to your project. Please understand
this form is only designed and distributed to aid the City in our street / utility excavation
permit process. 0
e®
A refundable deposit of is being collected at the time of your permit
application.
The City reserves the right to NOT refund this deposit if any of the following conditions
occur during the construction period:
1) All required permits have not been obtained.
2) All required inspections have not been obtained, especially the pre -pour inspection
of the street patch.
3) Soil compaction test results are not filed with the City.
4) The street patch is not poured within 3 days of the passing utility connection
inspection.
5) Theft of water service by the plumber, owner or general contractor
6) The project is completed without a final inspection being done.
If any or all of these situations occur during construction, you may forfeit your deposit.
Engineering Firm who will provide soil compaction test
I have read the above disclosure and conditions and accept this street / utility excavation
documentation on my own behalf assuming full responsibility as the owner / contractor for
this project. I further understand that should any or all of the above violations occur, the
permit deposit SHALL be forfeited or discounted upon the discretion of the City of Blair
Building Department.
Owner/ ccupant Contrac or
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City of Blair Date
[auu.HOUSao i
218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 -426 -4195 • E -mail cityofblair @ci.blalr,ne.us ••ooa. R.
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