1326 Park StFee: Paid:
Owner
Name: `yf ' 4 -Name: /14Yc-
f
Address:
le
The above described person is hereby granted a permit to (Move) o Demohsh)
building feet long, and feet high, now located on
j, g_;2Lv , 44 J , City of Blair, Nebraska, to be fmally located on
. The (Move) o Demolition) is to be done on
and shall take hours. The route to be taken in the
removal thereof is as follows: (Here designate the names and numbers of the streets,
alleys, or public grounds to be crossed):
The removal thereof shall be under the direction of the Street Commissioner and the
Director of Public Works. The building is to be used for purposes.
A statement that all taxes and special assessments on the building to be moved or
demolished and on the land from which it is to be moved or demolished have been fully
paid was received Oci-L t and is attached. A corporate surety bond or two
(2) personal sureties to pay all damages that may be sustained to any property, public or
private, and including curbs, paving, manholes, public utility lines and pipes, by reason of
., x �
the moving or demolishing of such building was received on
and is attached.
Permit to Move Building or Demolish Structure
Date:
Address: ,r. 2 5 / 4%, "
City Administrator
Contractor
(J o;'it4
PRODUCER
aR M CERTIFICATE OF LIABILITY INSURANCE
1 - 220_4625 I DATE(MM /DDNY)
Holmes Murphy and Associates
Omaha THIS CERTIFICATE IS ISSUED 0 FORM
Suite 200
ALTER THE COVERAGE
2637 South 158th Plaza ONLY AND CONFERS NO AS A MATTER OF INFORMATION
Si HOLDER. THIS CERTIFICATE DOES NOT THE CERTIFICATE
Omaha, NE 68130 AMEND, EXTEND OR
AFFORDED BY THE POLICIES BELOW,
INSURED INSURERS AFFORDING COVERAGE
Negus -Sons, Inc.
P.O. Box 12459 INSURERA:
INSURER B:
Omaha, NE
68112-0459
I
COVERAGES
ANY THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO
REQUIREMENT, E PERTAIN, TUR OR CO NRDEN O THE POLICIES DESCRIBED ANY RACT OR OPAACUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PqID (p CLLAIMS.
ANY VE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
INSR HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANn rye i
.LIR TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
3 D 6 4873-09 DAIEIMM/DD/YYl
08 D4 ./
01/01/08 01/01/09 09
A GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR
X $3,000 Property Damage
X Ded Per Occurrence
GEN'L AGGREGATE LIMIT TX] F OT X APPLIES
POLICY LOC
A AU"OMOBILE LIABILITY
X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
X OCCUR ❑ CLAIMS MADE
DEDUCTIBLE
X RETENTION
)THER
$10,000
3 E 6 4873 -09
3 J64873 -09
WORKERS C OMPENSATION AND
EMPLOYERS' LIABILITY 3H64873 -09
PTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
=KATE HOLDER
I ADDITIONAL INSURED; INSURER LETTER:
E Blair
16th St.
NE 68008
25 -S (7/97) chenryne
9413991
USA
INSURER C:
I INSURER D:
I INSURER E:
0 1/01/08
0 1/01/08
01 /01/09
01/01/08 01/01/09
Certificate Delivery by Certificates Now - ww w.ConfirmNet.corn - 877.669.8Bnn
LIMITS
EACH OCCURRENCE
($
I FIRE DAMAGE (Any one fire) $ 300,000
I MED EXP (My one person) $ 10,000
I I PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMP /OP AGG 1$ 2,000,000
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
i PROPERTY DAMAGE _ I
(Per accident) $
I AUTO ONLY - EA ACCIDENT ! $
OTHER THAN EA ACC I $
AUTO ONLY:
01/01/09 AGGI$
EACH OCCURRENCE
$ 6,000,000
I AGGREGATE i s 6,000,000
$
I X I WC STATU- OTH-
TORY LIMITS I I ER
I E.L. EACH ACCIDENT $ 5 00,000
E.L. DISEASE - EA EMPLOYEE! $ 500, 000
E.L. DISEASE - POLICY LIMIT I $ 50 0,000
$
DITIONS OF SUCH
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
RE PRESENTATIVES.
AUTHORIZED REPRESENTATIVE ad.
ACORD CORPORATION 1988