MS Registration 2021L -4 ALI 1-1211
218S. 16th 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:
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: ❑ Contractor- $60.00 Tree Trimmer - $60.00
❑ Electrical Contractor- $60.00 ❑ Drain Layer - $60.00
❑ Gas Line Installer - $25.00 ❑ Fire -Security System Installer -$25.00
❑ Mechanical Contractor- $60.00 ❑ Water Service Line Installer - $60.00
❑
Plumbing
�Contractor- $60.00
Business Name: "" "Z ' i Z 6-
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Applicant Name: / / nn ff
Business Address: l �`�l`r City:�(``% State: Ivy Zip:
Mailing Address: �' City: State: Zip:
Email Address: crow¢
Phone #: L10,2 �%3 / Fax #: Mobile
Business Address outside of Nebraska:
City: State I /
Contact Person:
/"r• SGL
Number of Employees: Apprentices:
Other Licenses Held:
Zip: Phone:
Journeymen:
Insurance/Worker's Compensation Company: ✓ � S ! Y l� zo /
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. 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 d an re ew Is e
-
thorized Signature Date
9/23/21, 1:00 PM Official Nebraska Department of Labor - Contractor Registration - Contractor Details
Contractor Details
Contractor/Subcontractor Name
Corporation Name
Business Entity
Address
City
State
Zip
Telephone
Registration Number
Registration Expiration
Sales Tax Option
Number of Employees
Worl<er's Compensation Status
M S Wiekhorst Arbor Company, LLC
LLC
12 Ginger Cove Rd
Valley, NE 68064
Valley
NE
68064
(402) 215-6739
83753-21
1/22/2022
2
0
Exempt
https://dol.nebraska.gov/conreg/Contractor/Details/8375321 1 /1
City of Omaha
Parks, Recreation and
Public Property Department Issued
second Class Arborist License
MICHAEL WIEKHORST
#209999-19
EXP: 12/31/21
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