JTech Registration 2017.tifA
218 S. 161h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraska.org
FOR OFFICE USE ONLY
Date Paid:
a
Receipt No: I I
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 Name:, A;/Ike,
Business Address: �Q� GLS/e6� �JU City: y State:��Zip/AJC
Email Address:/mac JJ IcT�G�I
Phone #: � - 3/-� Fax #:
Business Address outside of Nebraska:
City: State
Contact Person:
Number of Employees: 3g Apprentices:
Other Licenses Held:
Insurance/Worker's Compensation Company:
Zip:
Mobile#: 7Z_ —9r5%�/_
Phone:
Journeymen:
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 with the certificate holder being the `"City of Blair".
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. 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.
1 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 end any renewals thereof.
ALdhoriz Signature Date
,g`Y l
9/29/2017 https://dol.nebraska.gov/conreg/SearchContractors/ContractorDetails?regNum=22379
SEARCH REGISTERED
CONTRACTORS & SUBCONTRACTORS
Contractor/Subcontractor Name
J -TECH CONSTRUCTION
Address
6030 Havelock Ave
City
LINCOLN
State
NE
Zip
68507
Telephone
(402) 261 - 3682 (402) 520 - 5185
Registration Number
36130
Certificate Expiration
12-15-2017
Contractor Option
2
Number of Employees
40
Back to Results
@2017 - NDOL Contractor Registration. For assistance call 402-471-2230
https://dol.nebraska.gov/conreg/SearchContractors/ContractorDetails?regNum=22379