USM Registration 2018.tifCITY O C � �' � FOR OFFICE USE ONLY
(- Date Paid: 3 - 1
218S. 16th Street Receipt No
Date Issued
Blair, NE 68008 BOND EXPIRES.
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraslca.org
Application is: ElNew )k�enewal
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
El
Gas Line Installer- $25.00
Mechanical Contractor - $60.00
❑
Plumbing Contractor- $60.00
❑
Drain Layer- $60.00
Business Name:
r
Applicant
Business Address: /0?05? Cityzo tate: Zip:
Email Address: [ i /� ( 5- &,W-4 Inez
Phone AWOVY-471% Fax #: � �/ /P � Mobile #: 41N -A57 Zoo C '�
Business Address outside of Nebraska:
City:
Contact Person:
State
Zip: Phone:
Number of Employees: Apprentices: l Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company:C�%G�"i
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.
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 registration and any renewals thereof.
1/// ? L
Authoriz dsIgnature Date
CITYOF B LAIR FOR OFFICE USE ONLY
Date Paid:
218S. 16th Street Receipt No:
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebrasl<a.org
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:
Master's Name:
Business Address: Cityir / State, Zip:.�(p
Phone #:� �r'O%9 Mobile #:
Please List all employees that you wish to register and check the appropriate boxes.
Name Plumber Heater Electrician Apprentice Journeyman
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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 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 registration and any renewals thereof.
Authorize ignature Date
r o
4/12/2018
https://dol. n ebraska.gov/conreg/SearchCo ntractors/ContractorDetails?reg N u m=28234
SEARCH REGISTERED
CONTRACTORS & SUBCONTRACTORS
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2018 - NDOL Contractor Registration. For assistance call 402-471-2230
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