MS-2011-00271_0003.tif i
Cit of Blair Paid Invoice
218 S 16th Street Page 1 of 1
Blair, NE 68008
DATE INVOICE #
Mrs of a- Phone: (402) 426 -4191
7/12/2011 2011 -00910
Fax: (402) 426 -4195
PAID DATE 7/12/2011
ACCOUNT:
Jason Shryock
1228 S St PERMIT NUMBER MS- 2011 -00271
Blair NE 68008 1228 South St
Phone: 402 533 2694 BC LOT 10 _PT OF VAC ST BLK 72 112 PC 10
Blair, NE 68008
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Date Status Payment Amount
7/12/2011 OriginalDue 65.00
7/12/2011 Paid CheckCheck#1 147 Receipit#29317 ( -) 65.00
Total Paid 65.00
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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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