MS-2011-00469_0004.tif City of Blair P aid Inv oice S ummary
218 S 16th Street Page 1 of 1
Blair, NE 68008
DATE 10/21/2011
te a°
/s 0 1 a� Phone: (402) 426 -4191
Fax: (402) 426 -4195
ACCOUNT:
Robinson Construction
1210 H St
TEKAMAH NE 68061
Phone: 402 808 4103
Date Reference Number Invoice Number FeeCat Description Status Amount
10121/2011 2011 -01119 01- 002 -2631 Building PermitDeposit Paid ( -) 50.00
Date InvoiceNum Status Payment Amount
10/21/2011 2011 -01119 OriginalDue 50.00
10/2112011 2011 -01119 Paid CheckCheck #1392 ( -) 50.00
Total Pa 50.00
1 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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