Eyman Registration 2019.tif-A -
218
A
218 S. 161h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraslca.org
FOR OFFICE USE ONLY
Date Paid: i— —
Receipt No:
Date Issued: g ~
BOND EXPIRES:
CHANGEIADDITIONS FORM
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink — If you need more space, please attach additional sheets)
Master Plumber/Heater/Electrician - $60.00 each
Application is for: Journeymen/Apprentice - $25.00 each
Business Name:
E -Mail Address: v✓ Q--1-24t-5-Y-?jj M r,/ . C o 0
Phone #: Mobile #:
Please List all employees that you wish to register and check the appropriate boxes.
Name Master
Plumber
Heater
Electrician
Apprentice
Journeyman
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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.
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 and any renewals thereof.
Authorized Signature Date
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This certificate is non -transferable
Registration ## 21387-18
Date Issued: 9/15/2018 Date Firing: 9/15/2019
EYMAN PLUMBING, INC.
8506 S. 117TH STREET
LAVISTA, NE 68128
Nebraska Department of Labor
550 South 16th Street �.
Lincoln, NE 68508
402-471-2239 Oommissioner of Labor