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2. City of

    Fairbury

   Nebraska

   Founded to Move Forward

                                                   612 D. Street, Fairbury, NE 68352

4. APPLICATION 

   TEMPORARY US PERMIT

   FEE $10.00

6. DATE OF APPLICATION:
   DATE OF APPLICATION:
8. CELL PHONE NUMBER:
9. ALTERNATE PHONE NUMBER:
11. Email Address
13. Applicant Name:
15. Address
17. Applicant Address:
19. Site Address:
21. Describe Use/Purpose:
23. Hours of Operation:
24. Plan Attached:

    1. Yes
    2. No
26. Applicants Signature & Date:

    To be signed at when permit is picked up and paid.

28. [TO BE COMPLETED BY OFFICE STAFF ONLY]

30. PERMIT ISSUE DATE: ___________________

    PERMIT EXPIRATION DATE: _____________

    ZONING ADMINISTRATOR SIGNATURE: ___________________________

                                                                                     LAURA BEDLAN

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

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