2292.tif f
CITYOFBLAIR
218 S. 16TH STREET
BLAIR, NEBRASKA 68008
Buil Permit Applic (402) 426 -4191 -Phone
(402) 426 -4195 - FAX
MS -2014 -02292 °ters of a�a\` www.blairnebraska.org
08/19/2014 brwheele MISC Residential August 19, 2014
LOCATION OF IMPROVEMENT: 564 S 17th St, Blair, NE 68008
ARCHITECT:
GENERAL SELF
a �
OWNER: Ronald R And Gloria Jensen CONTRACTOR:
564 S 17th St
Blair, NE 68008
r� BLAIR, NE 68008 -0000
u r
t
w
NATURE OF WORK STRUCTURE
Misc. Permit Primary Structure
PROJECT NAME PERMIT EXPIRES 08/18/2016
564S1 7thSt-1 40819-2014 Storm Damage ESTIMATED COMPLETION DATE 12/3112014
DESCRIPTION OF WORK
Roofing, siding, gutters, windows
DEPOSIT PAID BY: SITE PLAN SUBMITTED: NA
Contractor
REScheck/COMcheckSUBMITTED: NA
DEPOSIT STATUS: BUILDING PLANS SUBMITTED: NA
$50
..�/A.xa.,�
m � �
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 application.
M t
Date
Signatu of Applicant
i
f
k
i
4
f
Y,
4
,
Y
r� J d
Promise
O
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.
A $200.00 refundable deposit is being collected for any residential remodel,
a dditi on or accessory building valued under $10,000.
A $50.00 refu able deposit is bung 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.
y
Con r ctorlOwner Contractor /Owner
City of Blair
i
L-
1
Date