RemodelN Registration 2016.tifCITY OF BLAIR
218 S. 1611 Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building 9blairnebraska.org
FOR OFFICE USE ONLY
Date Paid: o - 4 6
Receipt No: , , - C
Date Issued:
BOND EXPIRES:
Application is: 'R New ❑ Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
Please type or print in ink — If you need more space, please attach additional sheets)
Application is for: D�r Contractor - $60.00 ❑ Electrical Contractor - $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: ���oc�c� N-Cbrdl, trA , LLC
Applicant Name:���
Business Address: �22�7 S 1-1 V' nV6 City: Grtf-n6L State: * Zip: Aag
Email Address: 4AGk (�, V eM 04 -Cl W ' tOm
Phone #: "I V2-�0 r ?'q VZ Fax #:
Business Address outside of Nebraska:
City:
Contact Person:
Number of Employees:
Other Licenses Held:
State Zip:
6 Apprentices:
Mobile #:
Phone:
Journeymen:
Insurance/Worker's Compensation Company: �n5�►'d
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
Securitv Svstems Installer will need to submit a copv of vour Nebraska State License.
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. 1 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 liT
e and or re " tr 'o d any renew hereof.
Date
Department of Labor
Labor Law / Contractor Registration
4WNEBRASKA 550 South 16th Street, 3rd Floor
DEPARTMENT NT O LABOR Lincoln, NE 68508
(402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name: Remodel Nebraska, LLC
Address:
City:
State:
Zip:
Telephone:
Certificate Number:
Certificate Expiration:
Contractor Option:
12227 S. 217th Ave
Gretna
NE
68028
(402) 690 - 2782
48370
08/15/2017
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