PAID INVOICE (3).TIF Due Invoice Summary
City of Blair
218 S 16th Street
Blair, NE 68008
Phone: (402) 426 -4191 DATE 12/5/201;
a, \`�� Fax: (402) 426 -4195
o � /se of A I
ACCOUNT:
Ray Martin Co. of Omaha
6201 Center St PERMIT NUMBER ME- 2012 -00
Omaha NE 68106
Phone: 402 553 7300 ET 12 2242 Wright St
Blair, NE 6800E
Date Reference Numbei Invoice Numbei FeeCal Descriptior Status Amount
12/5/201', ME -2012 -0055; 2012 -0137: 010004202 Mechanical Fixture Fee: Due 75.00
12/512012 ME- 2012 -0055: 2012 -0137: 010004202. Mechanical Permit Issuance Fe( Due 25.00
Total Due
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions
of laws.
S' natur of Contractor or Authorized Agent
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