150 S 11th StFee Paid:
Name:
Address:
Permit to Move Building or Demolish Structure
Owner
C
Ir�O (I` \Fs), # 1 7 /
r�c
Date:
Name:
Address:_
City Clerk
City Administrator
Contractor
2 f
The above described person is hereby gr ted -a. permit to (Move) (DemoliA) a
X
building feet long, and feet high, now located on (71�.} , r ((a r !e( (Utz
City of Blair, Nebraska, to be finally located o
Demolition) is to be done on
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):
) and shall take hours. The
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 '1 > i (AC '
. The (Move) or
4' Ci / 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 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
the moving or demolishing of such building was received on
and is attached.
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DATE:
ION J. EMI IN
WASHINGTON COUNTY TREASURER
P.O. Box 348 ® Blair, Nebraska 68008
(402) 426 -6888
TO WHOM IT MAY CONCERN:
ON THIS DAY ( y
c & i57
PAID THE TAXES ON
U J 1 l
n C,tr7A
FOR THE YEARS OF (IC)
. PLEASE CONTACT OUR OFFICE IF
THERE ARE ANY QUESTIONS REGARDING PAYMENT MADE.
THANK YOU,
KAY J. ERWIN
BY: ' \1A
progrerrk rowan/Er Change Effective: • POLICY NUMBER - ,- . i4_9_-_o__
REQUEST FOR POLICY CHANGE DATE 6-6- as' INSVRED FULL NAME.
CAM
- Complete only or change$ desired- TIME .__- 0 PM STATE
INDICATE TYPE OF CHANGE: (C) Change (A) Add (D) Delete
NAMED INSURED INFORMATION AGENCY
TYPF Or
CHALICE
FIRST NAME
)e ery MAILINU AbDil SS AND ZIP CC I
lin , 5 : 77 I ,��r -
CAR I O ADDFE•9S AND TIP CODE
DRIVER INFORMATION
TYPE OF I NAME OF OPERATOR
CHANGE.
DRIVERS LICENSE NUM€}Eh /SS$
VEHICLE INFORMATION
TYPE
OF
CHANOE
On).16 -c I )
DRIVER
CLASS
TYPE OF
CHANGE
NAME
VEH,
VEH
T ERR
TYPE OF VEH.
CHANGE
FORM NO. B131 (12•ED CENTRAL
POINT
CLASS
Don tiny h I i da I Ins.
SEX
LP or Al? NAME /ADDRESS /CITY /STATE/ZIP
❑ ❑
MARITAL
STATUS
STATE
DRIVER DAIS DESCRIPTION OF ACCIDENTS /VIOLATIONS
1 1 1 1 1 1
PLEASURE BUS. FARM
LOSS PAYEE On ADDITIONAL INTEREST INFORMATION
FILING INFORMATION
FILINO REQUIRED? I TYPE? STATE CASE
O YES 0 NO D OWNER C7 OPERATORS
I DATE OF OCCURRENCE REASON
- 1
RELATION
TO INSURED
LAST NAME
'e
CREDITS /SURCHARGES
402 721 8154 P.01
CODE
DATE OF BIRTH
ACCIDENT S /CONVICTIONS /LOSSES (if driver added) USE SEPARATE SHEET IF NECESSARY
PLACE $ DAMAGES PAID
INJURY ( PD
TRADE NAME AND MODEL NAME COST NEW SYMBOL
YEAR 'IODY TYPE, YDOORS, XCYL OR COI VIN /SERIAL NUMBER OR AND
(2dr, ddr. SW, VAN, P /U, 4X2 OR 4X4) STATED AMT. AGE
i ' it Cr l ,IYQ O »1 ( I i l l 1 1 1 J 1 1 .1 1 1 I 1 /
1 1 1 1( 1 1 1 1 1
WORK/ MILES ONE WAY
SCHOOL WORK /SCHOOL
OCCUPATION
/
Company Use Y°
AT FAULT?
YES I NO
CREDITS /SURCHARGES
COVERAGE INFORMATION (Indicate Limits and /or Deductibles)
BODILY INJURY U.M. AND /OR MEDICAL PHYSICAL DAMAGE ADD ON
I PROPEI:ITY DAM. U.I.M. PAYMENTS COMP, /COLL. EQUIPMENT
LIMITS LIMITS LIMIT DEDUCTIBLES S AMOUNT
Remarks C,-( C4 40aity -6 6
JN YbD / PROCESSED VERIFIED
DON 11111,10;11, INSURANCE
224 NOR/71 lbi/Ar STREET
FREMONT, NE 68025
402 721-791(1
nitrE. 6-as___
, err ti3e:Z
PRUAI: Pa-174/
SUBJECT:
Don Vy h I i eta I Ins.
402 721 8154
P. 01
l
Activity Pending
1001 c Number:
;Policy Term:
li Cancel Effect: Date:
Confirmation Number.
VY1iLIDAL INSURANCE itr�� Jut
Hsme ! Nett 1 Contct Us 1 Ste_ 1 $
=Pclicy ,..iPAymehts , Documents
!N ame; Jer R Sager
�A dress:
50 South - 11th'Trir 17, Nair, NIE 58008.
!Phone: Home: (402) 533 -B45S Work: (402) 533 -8456
®� Ack1r V"sS
Vehic
'/Details of Cane:
jlPc]icy currently has a CancFl CamFa`_2 pe[dSng.
4.ev refurLe win be credited -' _he SET ;
Driver
Agent
Poly:
Term:
~Status:
A policy cancellation is pending. Quotes and ctlangss at not available online.
This cola; ye was reotrwsied by Patty, Agent via the Customer Service on 06f06!2005 at 10:24 AM_
Summary of Policy Activity
lI375551 59 -0
j;01 /1212005 to 01/1212006
I06n6, /2005 at 12:31 AM
N57N1J1.59
Ccverage
81302
37555159-0
01/12;2005 to 01;12 2006
Active, billing is paid o dale
Limitations to Orli' Policy ,C .hianeers
:I
i
•
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