NebraskaI Regristration 2021Z 18 S. 16th Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraska.org
Application is: XNew ❑ Renewal
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
❑ Gas Line Installer- $25.00
0--- Mechanical Contractor- $60.00
❑ Plumbing Contractor- $60.00
Business Name: K[(�G I S � GL i u 5-�" Cf
Applicant Nam
Business Address:
Email A
❑ Tree Trimmer- $60.00
❑ Drain Layer - $60.00
❑ Fire -Security System Installer 425.00
❑ Water Service Line Installer - $60.00
01 (rG Lfiy7 , G .
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{'1 ��F' � City: o � �� State: � � Zip: ��
I� f—C / 0) YYd Gi f I i 0 V7/1
Phone #: qdO'� ` i q 5- q -10 0 Fax #
Business Address outside of Nebraska:
Al4-
ile#: [/-0�-qq qJ % -100
City: (, State _ Zip: Phone:
Contact Person: C t d 114 f7 neveill _�F_ V-1
Number of Employees: Apprentices:
Journeymen: J
Other Licenses Held: (A r] I tL6Mca I C r�1��1 �(lS�l' T` , ' , l�� 01- j � G -fah" I`1f�
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Insurance/Worker's Compensation Company: _ i1 R"
e- 'r e r _ n
� l I t r,(R C jZ __
Electrical, Gas Line Installer, Mechanical, Plumbing Contractors and T ee Trimmers need a $5,000 permit bond stating John Doe
dba Company Name" 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 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 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 an rere als thereof.
Authorized Signature Date
FOR OFFICE USE ONLY
Date Paid.,
Receipt No.
a
Date Issued:
BOND EXPIRES: —
Application is: XNew ❑ Renewal
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
❑ Gas Line Installer- $25.00
0--- Mechanical Contractor- $60.00
❑ Plumbing Contractor- $60.00
Business Name: K[(�G I S � GL i u 5-�" Cf
Applicant Nam
Business Address:
Email A
❑ Tree Trimmer- $60.00
❑ Drain Layer - $60.00
❑ Fire -Security System Installer 425.00
❑ Water Service Line Installer - $60.00
01 (rG Lfiy7 , G .
Cv
a Var� Dr_-�,vevvf-ef_
f��
{'1 ��F' � City: o � �� State: � � Zip: ��
I� f—C / 0) YYd Gi f I i 0 V7/1
Phone #: qdO'� ` i q 5- q -10 0 Fax #
Business Address outside of Nebraska:
Al4-
ile#: [/-0�-qq qJ % -100
City: (, State _ Zip: Phone:
Contact Person: C t d 114 f7 neveill _�F_ V-1
Number of Employees: Apprentices:
Journeymen: J
Other Licenses Held: (A r] I tL6Mca I C r�1��1 �(lS�l' T` , ' , l�� 01- j � G -fah" I`1f�
�
Insurance/Worker's Compensation Company: _ i1 R"
e- 'r e r _ n
� l I t r,(R C jZ __
Electrical, Gas Line Installer, Mechanical, Plumbing Contractors and T ee Trimmers need a $5,000 permit bond stating John Doe
dba Company Name" 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 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 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 an rere als thereof.
Authorized Signature Date
218S.16 th 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: M. -ho 0 1 C
Master's Name: � �� Vq 1-1 Dulye o-�e__--
Business Address: t!/� yr v r i6 i V` l %r . City:'✓' r1 State:NL7zip 3 d -
Phone#: itis` `q61' q q-10 Mobile #:— a [I/ -I -e-,
Please List all employees that you wish to register and check the appropriate boxes.
[dame 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.
Authorized signature
Date
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