Goldenstein Registration 2021%MEN
i i I I i;
FOR OFFICE USE ONLY
Date Paid:
Receipt No:
Date Issued:
BOND EXPIRES:
Application is: ❑ New ❑ Renewal
CONTRACTOR REGISTRATION/LICENSE
(Please type or print in ink - If you need more space, please attach additional sheets)
Application is for: P] Contractor - $60.00
❑
Tree Trimmer- $60.00
❑ Electrical Contractor- $60.00
❑
Drain Layer- $60.00
❑ Gas Line Installer- $25.00
❑
Fire -Security System Installer 425.00
❑ Mechanical Contractor - $60.00
❑
Water Service Line Installer - $60.00
❑ Plumbing Contractor - $60.00
Business Name:
Applicant Name: �a o` c // G' --C/ (c%ef r! s
Business Address: P0, 10o X 1616-1 City: 7-e k -f 01a G, State: N e Zip:
Email Address: '��(c)e<, st�lli,co„C Yaloo ,C0 «,
Phone #: (1-(0,)_) 4- r - 6 5-7,(, Fax : Mobile :
Business Address outside of Nebraska:
City:
State
Contact Person: On f e, t r 5 le”,
Number of Employees:
Other Licenses Held:
Zip: Phone:
-C� - Apprentices: _0
Insurance/Worker's Compensation Company:
Journeymen: -Lf -
Electrical, Gas Line Installer, Mechanical, Plumbing Contractors and Tree 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
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.
1 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
5/4/2021 Official Nebraska Department of Labor - Contractor Registration - Contractor Details
CUILtractor Details
Contractor/Subcontractor Name
Goldenstein Construction
Corporation Name
Business Entity
Sole Proprietorship
Address
P.O. Box 104
Tekamah, NE 68061
City
Tekamah
State
NE
Zip
68061
Telephone
(402) 490-6576
Registration Number
98586-21
Registration Expiration
5/15/2022
Sales Tax Option
2
Number of Employees
0
Worker's Compensation Status
Exempt
https://dol.nebraska.gov/conreg/Contractor/Details/9858621 1/1