ZONING BUILDING PERMIT APPLICATION

KEYA PAHA COUNTY, NEBRASKA

This portion to be filled out completely by Applicant

1. The undersigned hereby applies for a permit for:  (check one)

______House Moving                                               ______New Construction

______Alteration/Enlargement                               ______Double-Wide Manufactured Home

2. Legal description of property to be affected by the activity proposed:__________________________________________________

 _______________________________________________________________________________________________________

3. Do you own this land?    Yes______    No______

If no, notarized permission from the landowner needs to accompany application.

4.  Proposed use of building to be affected by the activity proposed:______________________________________________________

________________________________________________________________________________________________________

5.  Size of building/addition ______X______                     Height in feet to top of roof : _____________

6.  Number of residential dwellings (including double-wide manufactured homes and single-wide mobile homes) on the same

quarter section as the building activity proposed in this application: ____________

7. On the second page of this application form, sketch a site plan of the activity proposed in this application which indicates all of the following:

1. Location and size of the proposed building/addition.

2. The location of all roads adjoining this property and the distance(s) from the centerline of any road(s) to the point of the proposed building location closest to the said road(s).

3. The distance to property line(s) of property under different ownership (if less than 300 ft.).

4. The location of other buildings within 300 ft. of the building/addition proposed in this application and the distance between these buildings and the proposed building application.

5. The location of any water well and sewage disposal system proposed to serve the building/addition proposed and the distance between the well and the septic tank and tile field or other sewage disposal systems.  Name and phone number of sewage disposal system contractor.

6. The location of any river, stream, or intermittent stream within 300 ft. of the building/addition and the distance to the proposed building/addition.

7. The location of the drive which will serve the building/addition.

8. If proposed building/addition is located in the AG-2 Agricultural-River Corridor Zoning District, indicate the type and location of screening which will screen at least 50% of the building from the upstream portion of the Niobrara River together with the location and type of other landscaping on the premises.

9. If the proposed use is a commercial, industrial or public use, indicate the number and location of all parking spaces to be provided, the location of loading areas and the proposed type, location, height and size of any signs to be placed on the premises.

8. I hereby certify that I have the legal authority to file this application, that I have completed and examined the application and know the same to be true and correct.  I further certify that all the provisions of law and other regulations governing the type of construction and use proposed in this application will be complied with, whether or not specified in this application, including any building, electrical or plumbing codes.

_____________________________________       ____________________________________________________________

Printed Name of Applicant                                       Mailing Address of Applicant

_____________________________________      _______________________       __________________________________

Signature of Applicant                                            Date of Application                       Telephone No. of Applicant

Sketch Site Plan Here:

Physical Directions to Property________________________________________________________________________________

________________________________________________________________________________________________________

This Section to be completed by Zoning Administrator

APPLICATION NO._______________, 20_________

1.  Building/Addition complies with set back distances from road(s) and between buildings.                            Yes____    No____

2.  Building/Addition complies with set back distances from property lines.                                               Yes____    No____

3.  Building/Addition complies with the height limitations.                                                                     Yes____    No____

4.  Building/Addition requires Special Exception approval.                                                                        Yes____    No____

5.  If proposed building/addition use is for commercial, industrial, or public use, minimum

  provisions for parking, loading areas, and signs will be complied with.                                         Yes____    No____

6.  Application fee of $25.00 was paid by applicant.                                                                                  Yes____    No____

 (Agricultural buildings are exempt from this fee)

7.  Application is:

Approved_______       Disapproved_______       Reason(s) for disapproval__________________________________________

____________________________________________________________________________________________________

Date of Approval/Disapproval_____________________, 20__________

______________________________________________________

Signature of Zoning Administrator