Homestead Registration 2021LAI
218S.16 th Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: ciWofblair@ci.blair.ne.us
FOR OFFICE USE ONLY
Date Paid: ,
Receipt No: r
Date Issued: _ ✓ , ._
BOND EXPIRES: 1,
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:P 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
0 09
Business Name: HOMESTEAD SOLUTIONS
Applicant Name: ADAM HOLMSTEDT
Business Address:. 2 n RnX 1?n5n City: OMAHA_ State:NF—Zip: 6sj2
Email Address, adamholmstedt@outlook.com
Phone #: 41719-686-4117 Fax #:
Business Address outside of Nebraska:
Mobile #:
City: I State I Zip: Phone:
Contact Person: ADAM HOLMSTEDT
Number of Employees LA Apprentices: Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company: NEXT INSURANCE #NXTZ6AUVNK-00-GL
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.
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.
Authorized Signature
02/25/2021
Date
NEBRA-&K�Nebraska Department of Labor
Contractor Registration
DEPARTMENT OF LABOR 550 5.1611' Street, Lincoln, NE 68508
(402) 471- 2239
Registration tt86056-21 11VWWAo1.nebraS1«. gv
Affidavit for Contractor Registration Fee Exemption
I, ADAM HOLMSTEAT of HOMESTEAD SOLUTIONS located at P.O. BOX 12050, OMAHA, NE, 68112, being duly sworn, depose and say that;
1. I am a Sole Proprietor and have no employees,
2. Listed below are the individuals I currently employ and have previously employed in the last 12 months.
Current Employees:
Name
Address
Past Employees:
Name Address
City State Zip Phone
City State Zip Phone Amount Paid
3. I have provided the Nebraska Department of Labor, Labor Law/Contractor Registration Office, a complete listing of all contractors/subcontractors used in
operating my business. I have ensured all subcontractors are properly registered in accordance with the Contractor Registration Act PRIOR to commencing any
work for my business. If the Department locates any unregistered contractors working for me, they will be presumed to be my employees per the Nebraska
Employee Classification Act, 48-2903(b). I will be issued a $500.00 citation per misclassified individual/unregistered contractor, and I will be responsible for
providing proof of Workers' Compensation Insurance and Unemployment Insurance. I will also be responsible for any applicable contractor registration fees.
4. If at any time I no longer qualify for exemption from the fee, I will notify the Nebraska Department of Labor at the above address, and pay the registration fee
as required by the Nebraska Contractor Registration Act.
State of;
County:
Contractor's Signature
� �� 1%�.� — "
On this 1—day of 1 Y (A vY l . 20—TI N(Ay I 1 I l 1) YI J k d t personally appeared before me, whose identity was
proved on the basis of satisfactory evidence to be the person whose name is subscribed on the foregoing document and acknowledged that he/she
executed it. Witness my hand and official seal.
Public
OTARY • State of Nebra 101/Z
GENE r JULIA AKINS My ommission
My COMM. Exp, October 9, 2024