PAID INVOICE SHEET.TIF i
City of Blair
Paid Invoice Summary j
218 S 16th Street Page 1 of 1
Blair, NE 68008
" DATE 12/712012
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rse °, a ° �� Phone: (402) 426 -4191
Fax: (402) 426 -4195
I
ACCOUNT:
A & S Services Inc.
911 W Hwy 10 PERMIT NUMBER AD -2012 -00551
Orange City IA 51041 600 S 1st St
Phone: 712 737 8877 N1/2NW1/4, SE1 /4NW1/4, NW1 /4SE1/4 TL
10,28,29,30,31,32,33,38 46 18 -18 -12 12B PC 7 444.53
AC
Bl air, NE 68008
Date Reference Number Invoice Number FeeCat Description Status Amount
12/7/2012 AD- 2012 -00551 2012 -01380 0100020229 Building PermitDeposit Paid ( -) 500.00
12/7/2012 AD- 2012 -00551 2012 -01380 0100042024 Building Permit Fees Paid ( -) 1382.00
12/7/2012 AD- 2012 -00551 2012 -01380 0100042024 Building Permit Issuance Fee Paid ( -) 25.00
Date InvoiceNum Status Payment Amount
12/712012 2012 -01380 Original Due 1907.00
12/7/2012 2012 -01380 Paid Check Receipt #32309/ ck # 14154 ( -) 1907.00
Total Paid 1,907.00
1 hereby certify that I have read and examined this application and know the same to be true and correct. All
provisions of laws.
/2� /1
i nature of Contractor or Authorized Agent
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