MidlandU Registration 2016.tifCITY OF BLAIR
218 S 16TH STREET
BLAIR, NE 68008
(402) 426 - 4191
FAX (402) 426 - 4195
Email: cityofblair@ci.blair.ne.us
FOR OFFICE USE ONLY
Date Paid:
Receipt No:
Date Issued:
BOND EXPIRES'
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Midland Utility Service, Inc.
5240 Co Rd 40
Ft. Calhoun, NE 68023
Phone numbers on record:
Type: Phone Number:
Office
Mobile
Email Address:
402 573 5018
402 681 2015
Type: Rhone Number:
Please verify and correct
the company/business
information listed here.
PLEASE SUBMIT A Copy OF i. i
LABORcA
O,
Type of Business: DRAINLAYER PLEASE SUBMIT COPY
UUK
Please submit new reciprocating license or those which have expired: CURRENT' CITY OF OF
BENS
p 9 f p OMAHA LICENSE
Name Reciprocating License Expires
Kimberling, Steve Omaha Plumber License 12/31/2015
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Kimberling, Steve Drainlayer Bond 4/20/2016
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
ltI — Kimberling, Steve Drainlayer 12/31/2015 $60
Please list any additional license or registrations:
Name License / Registration Amount
All information contained in this application is true and correct. I will notify the City of Blair of any changes in the
information reported on or with this application form within 15 days of change.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and experienced to
engage in above said vocation. I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
voc tion and yobeall order requirements and regulations of its lawful constituted authorities.
di JLf 10,4 At,'
Authorized ignature QLJ Date
4.-
Date Expires
Date Issued
11/1512016
DEPARTMENT Of LABOR'
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iSF.So, 16th ftget-LikPig" N
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Fee Paid; $40.00V,
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Business;
MbLAND UTILITY SERVICE
14554 GROVER STREET
OMAHA, WE 69154
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