Chet Registrstion 2016.tifCITY OF BLAIR
218 S. 16th Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraska.org
FOR OFFICE USE ONLY
Date Paid:
Receipt No:
Date Issued:
BOND EXPIRES:
Application is: 0 New ❑ Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink - if you need more space, please attach additional sheets)
Application is for: � Contractor- $60.00 1-1ElectricalContractor - $60.00
❑ Water Service Line Installer - $60.00 ❑ Tree Trimmer- $60.00
❑ Fire/Security System Installer - $25.00 ❑ Gas Line Installer - $25.00
❑ Mechanical Contractor- $60.00 ❑ Plumbing Contractor - $60.00
❑ Drain Layer - $60.00
Business Name: 6Y ET C�������
Applicant Name: 1. fIn-
Business Address: 6 Z_ L-0 �s T- City: State: !V L; Zip: L V5_7
Email Address: I e d UCS I (V60K n e 'f
Phone #: " 1 O Z- q Z6 -/I d,�_ Fax #:
Business Address outside of Nebraska:
City:
Contact Person:
Number of Employees:
State
Apprentices:
Mobile #: ry Z r M
Zip: Phone:
Journeymen:
Other Licenses Held: �Cltl_clvor cp_51S
Insurance/Worker's Compensation Company: // �� fir' 1/
Drain Layers/Electrical, Plumbing and Mechanical Contractors/Water Service Line Installers need a $5,000 permit bond in favor
of the City of Blair. Tree Trimmers need a $5,000 permit bond in favor of the City of Blair. Electrical Contractor and Fire
Security Systems Installer will need to submit a copy of your Nebraska State License.
General Contractors need to submit a Certificate of Insurance with minimum limits of $1,000,000 Aggregate/$300,000 each
occurrence.
All types of registrations must include proof of registration with the Nebraska Department of Labor.
All information contained in this application is true and correct. 1 will notify the City of Blair of any changes in the information
reported on or with this application form within 15 days of the 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
vocation and obey all order, requirements and regulations of its lawful constituted authorities. This certification applies to the
original licen a and/ registration and any renewals thereof.
IV714
Authori d Signature Date
11 -CRA