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AirT Registration 2020218S. 16th Street Blair, NE 68008 (402) 426 4191 FAX: (402) 426 4195 Email: building@blairnebraslca.org FOR OFFICE gUSE ONLY Date Paid: Receipt No: Date Issued: BOND EXPIRES: cu Application is: ❑ New ❑ Renewal CONTRACTOR T'I/L0 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 Mechanical Contractor - $60.00 ❑ Plumbing Contractor - $60.00 ❑ Drain Layer- $60.00 Business Name: Applicant N Business Address: l (� �� �i lfir �d City: Email Address: 1(Y� 1 I V's C Phone #: �f©a` Z% ? _J 6V Fax #: Business Address outside of Nebraska: City: Contact Person: Number of Employees: Other Licenses Held: State Zip: Apprentices: ++ � I/I State:_l�, Zip: Y obile #: LIyQ' ?% 3 Phone: Journeymen: Insurance/Worker's Compensation Company: &!; U KAL l C t A04-1 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 IS 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. 1 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. _X17:�LC--V - /D --7-a6 Authorized Signature Date • 0 ■11 218 S. 161h Street Blair, NE 68008 (402) 426 4191 FAX: (402) 426 4195 Email: building@blairnebraska.org FOR OFFICE USE ONLY Date Paid: Receipt No: Date Issued: BOND EXPIRES: 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:v�\ 7iRenWw aC4 6o/� Master's N _ 1 I Business Address: i c'�� lUI d W`, Yb d City: AW State: M Zip G � Phone #:( _S�6 Mobile #: !no Please List all employees that you wish to register and check the appropriate boxes. Name Plumber Heater Electrician Apprentice Journeyman ❑ ❑ ❑ 1�f ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 IS 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. 1 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 0 I m c) uj Ac - III CO C) 21 W CO ro r-) i; U i 0 0 C:) 2 U) D