AD-2011-00182_0003.tif Cit of Bair aid Invoice Summary
218 S 16th Street Page 1 of 1
Blair, NE 68008
DATE 7112/2011
ArO MIse Of g Phone: (402) 426 -4191
Fax: (402) 426 -4195
ACCOUNT:
SELF
PERMIT NUMBER AD- 2011 -00182
Blair NE 68008
10920 Bridgeview Dr
Phone: OAK PARK FIRST ADDITION PART OF LOT 15 BLK 6
12B PC 15.98 AC
Blair, NE 68008
Date Reference Number Invoice Number FeeCat Description Status Amount
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7/12/2011 AD- 2011 -00182 2011 -00849 0100020229 Building Permit Deposit Paid ( -) 500.00
7/12/2011 AD- 2011 -00182 2011 -00849 0100042024 Building Permit Fees Paid ( -) 1045.00
7/12/2011 AD -2011 -00182 2011 -00849 0100042024 Building Permit Issuance Fee Paid (- )25.00
Date InvoiceNum Status Payment Amount
6/14/2011 2011 -00849 OdginalDue 1570.00
7/12/2011 2011 -00849 Paid Check Receipt #29320 Check #0901 ( -) 1570.00
Total Paid 1,570.00
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I hereby certify that I have read and examined this application and know the same to be true and correct. All
provisions of laws.
Signature of Contractor or Authorized Agent
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