ExteriorSo Registration 2014.tif FOR OFFICE USE ONLY
CITY OF BLAIR Dam Paid:
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Receipt NO: cte
218 S. 16" Street Date issued. —
BONDEXPIRES:—
Date 'Ssued,,
Blair, NE 68008 BOND ExpR
(402) 426 4191 FAX: (402) 426 4195 w .
Email: dvqLbl it @ei blair.rle.u� 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. TO Contractor- $60.00 ❑ Electrical Contractor- $60.00
❑ Water Service Line Installer- $60.00 ❑ Tree Trimmer - $60.00
❑ Fire/Security system installer - $25.00 n Gas Line Installer- $25.00
F Mechanical Contractor- $60.00 ❑ plumbing Contractor- $60.00
❑ Drain Layer - $ 60.00
Business Name: o iL— �L,77t C-
Applicant Name: State: vt-, OY
9 JTx�, Cit �2p#M t Zip:
Business Address:
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Email Address- va J 1 0 �L T C
Phone #: �'5�136 Fax #: Mobile
Business Address outside of Nebraska.
City: State Zip _ Phone. •
e* rs
Contact P on.
Number of Employees: _Apprentices: Journeymen*
Other Licenses Held:
Insurance/Worker's Compensation Company:
Drain Layers/Electrical, Plumbing and Mechanical Contractors/Water Service Line Installers need a $s000 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 Aggregatel$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. experienced to
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and ex
nform strictly to the Ordinances of the city of Blair, Nebraska relative to said
engage in above said vocation. I agree to co
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.
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Authorized Signature
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NebraskaDepatimeutof Labor
Contractor Registration 2
550 So. 16th StrW, Lincoln, NE 68508
r (402) 471-2239
Date Issued Date Expires
04/15/2014 04/1512015
CONTRACTOR REGISTRATION CERTIFICATE
Tbis cerlscata is nw- franvfaabla
{ Fee Paid: $40.00 Registration #
26736
a;# Year
a 14
e Business:
EXTERIOR SOLUTIONS (��iwitt t
6624 BLONDO ST STE. A
OMAHA, NE 68104 Coromissiwecof r
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