Wiig Registration 2017.tifCITY OF B ! q FOR OFFICE USE ON
11pr
'J\ Date Paid:
Receipt No:
218 S. 161h Street Date Issued: _
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: building@biairnebraska.org 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 Name:IC LY S n V I
I� C
Business Address: o / L4 f
Email Address: i 4(
Phone #:4102_7jb -�/,;!6. Fax #:
Business Address outside of Nebraska:
City:
State
Contact Person: :5 'r,
Number of Employees: 1__— Apprentices:
Other Licenses Held:
City Stater Zip:.i� �r r
Zip: Phone:
Journeymen:
InsurancelWorker's Compensation Company: t) fn&_ Ta (f dUl.
Drain Dyers/E'lecti.101, Nam birig Service Laine lnstallers.need a $5,000 permit bond in favor
bf the City of Blair. Tree Trimmers need.a'$5,000 permit bond in"favor bf the Cit of Alt. E 0WIcal Contractor and Fire
Security Systems InstaileY:uvlll nse l to 3d mit a co iy of your Nebraslta State License.
General Contractors need to submit a Certificate of Insurance with minimum limits of $1,000,000 Aggregate/$300,000 each
occurrence with the certificate holder being the "City of Blair".
All types of.registrailons must Include proof of registration-,mrith the. Nebraska pepartlnent oft abo
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/or registration and any renewals thereof.
CE1✓i+tl1"orized Signature Date '
iWMA7 https://www.dol,nebraska.gov/conreg/SearchContractors/ContractorDetails?regNum=8061
SEARCH REGISTERED
CONTRACTORS & SUBCONTRACTORS
WIIG ELECTRICAL SERVICES, INC.
8014 s 92 AVE CIR
LAVISTA
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NE
68128
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(402)537-8I42
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25840
10-15-2018
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