Eyman Registration 2016.tifCITY OF BLAIR
218S.16 th Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: cit rofblairiDd.blainne.us
FOR OFFICE USE ONLY
Date Paid
Receipt No: !
Date Issued:®
BOND EXPIRES:
Application is: ❑ 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 ❑ 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:
Applicant
: I
Business Address: City: '� State v Zip:
Email Address; t g f) t - t 11) ?6
Phone #: �i�a. -'�� -: 2'� Fax*: 0,) `-231 _ `�`'� _��t ; Mobile #.
Business Address outside of Nebraska:
City.
Contact Person:
State
Number of Employees: 4 i, ° Apprentices,
Zip: Phone:
`s
Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company:
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 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 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 license and/or registry . n and any renewals thereof.
Wuthorlzec!'SlqnU4Date
CITY OF BLAIR FOR OFFICE USE ONLY
Date Paid:
218S.16 th Street Receipt No:
Date Issued: L1sY
Blair, NE 68008 p BOND EXPIRES: yy
(402) 426 4191 FAX: (402) 426 4795
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Email: cityofblair@ci.blair.ne.us
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink — If you need more space, please attach additional sheets)
Application is for: Journeymen/Apprentice - $25.00 each
Business Name: El m Ot o jLt
' ! �• L (�
Master's Name: Ti?�/
Business Address: 1S 5-06, 5 • UP") � T City: L6V 06 State: Zip:
Phone* f p ` - l - -� Mobile * V U a - S(-io - �)- 9
Please List all employees that you wish to register and check the appropriate boxes.
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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 the change.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 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 license and/ registration and any renewals thereof.
r
C�3 l
f Autho ize i e Date
Department of Labor
Labor Law / Contractor Registration
550 South 16th Street, 3rd Floor
Lincoln, NE 68508
(402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name:
Address:
City:
State:
Zip:
Telephone:
Certificate Number:
Certificate Expiration:
Contractor Option:
EYMAN PLUMBING, INC.
8506 S. 117TH STREET
LAVISTA
NE
68128
(402) 731 - 2727
21387
09/15/2016
1