DIRECTIONS: Please fill in the following required information accurately and completely. On an attached sheet, draw the shape of the property with dimensions. Show all existing and proposed buildings, including dimensions from the buildings to the lot lines.

The undersigned applies for a permit to erect / demolish a building on Lot _______Block _______,
_________________________Addition. Street Address_______________________

Owner Name: ________________________________________Phone: _____________________
Address: _______________________________________________________________________

Architect (if applicable) _____________________________________________________________
Contractor (if applicable) ____________________________________________________________

Nature of the use or occupancy ______________________________________________________
______________________________________________________________________________

Principal Dimensions (size): _____x_____x_____
Estimated Cost $ ________________________

General description and plans ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ATTACH A DRAWING OF THE PROPOSED STRUCTURE.

I hereby certify that the above statements are correct and that if building permit is issued all work will be done in accordance with the above statements, in accordance with any such rules, regulations, and precautionary actions as may be deemed necessary by the Governing Body, and in accordance with the ordinances of the City of Chappell. Nebraska.

Signed:____________________________________________________ Date: ________________

Approved / Disapproved ____________________________________ Date: ________________
Planning and Zoning Administrator
If denied, the reason for such denial is: ____________________________________________________________________________________________________________________________________________________________

ATTEST:
____________________________________
Permit Fee paid __________
Building Permit Number ________________ issued _______________________20___.