Corbion Registration 2020CITY OF BLAIRrom ctfri _�.wr ONLY
218 S. 16fil Street Dater kik ®- c1
Blair, NE 68008 Date Nr.;
(402) 426 4191 FAX (402) 426 4195 fo o tr�.t t: c
Email: building(ftlalmebrasimorg ��
Application Iv. 2r New ❑ Renewal
CON'T'RACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink _ If you need more space, please attach additional sheets)
APpOcation 1s for, 1" Contractor -,x60,00 ❑ Electric.ai Contractor e $60.00
❑ Water Service Lint: Installer- $60.00 ❑ Tree Trimmer- $60.00
FI. Seco
❑ city System Inscailer - S25A0 ❑ Gas Line Installer - S25.00
Mechanical Contractor -'560.00 Cj Plumbing Contractor- $60,00
Drain Layer- $60.00
Busintts Name: e✓ J C
Th L AL Ccv ra
Applicant Name:_.3, rf We'
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Business Address: 17 L1,rditS�7•'o0
. ��.� city: 8/a: r- State: � zip: L �"D '
ErrlailAddress^. �, 4JGi C� Q Cet-�►t o/L
Phone 0. '` IZ.�N�G 46 S `l62 5 3 3- 9-;V
ax lh. oboe y
Business Address outside of Nebraska: RA 50
city: LeY?CX Q State 1/ r�
Zip: G 6a?�5l Phone: 904
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Contact Person: 1 r- t- gni
Number of Employees ie Apprentices: O Journeymen: b
Other Licenses Held: N /*
Insurance/Worker's Compensation Company:_ A e vt Z/ I--,xy e e T S
Drain Lays rVoeciriql, Plumbing and Mechanical Contractorilwater Sella une Installers need a Ss 000 permit borrci In favor
of the City of Main Tree Trimmers freed a S5,000 per., bond in favor of the city of Blair. Elec'tri®i Contractor and Fire
Security SyXMM Installer will creed to submit a copy of your Nebraska State ucwmw-
Gionerai Contractors head to submit a Certificate of insurance with minimum llrnits of $1,000.000 AggregateVS300,000 each
occurrence with the certificate holder being the laty of alair".
All types of registrations must Include proof of registration with the Nebraska Department of tabor.
All information contained in this application is true and correct 1 will notify the City of Blair of any changes In the information
reported on or with this application form within 15 days of the change.
I hereby make application to the Licensing ;Board of Blair, Nebraska and certify that i am competent and experienced to
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engage In above said vocation. I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation and obey all order, requirements and regulations of its lawful constituted authorities. This certification applies to the
origlnal license and srt.registration and any renewals thereof.
�r �, c e i$+�t,T Q 3 l Aa, ' a.
Authorized signature �D t9 � � t� ante I
NTw �?ara��fa► r t �Cr�l�...-*,,"r�" i
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