Travis Registration 2021218S.16 1h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraska.org
FOR OFFICE USE ONLY
Date Paid: ` L
Receipt No: ,
Date Issued: t
BOND EXPIRES:
' 3
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 425.00
❑ Mechanical, Contractor. -:$60.00 ❑ Water Service Line Installer - $60:00
❑ Plumbing Contractor - $60.00
Business Name:
Applicant Name:
Business Address: City: State: Zip:
Mailing Address: ° ,"$ City ,r ,. State: Zip:
Email Address:
Phone #: ` : c r Fax #: `` - ` L Z� 9, Mobile #. s
Business Address outside of Nebraska:
City: State Zip! Phone:
Contact Person:
Number of Employees: Apprentices: Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company:
All information contained in this application is true and correct. 1 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 1 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, equirements and regulations of its lawful constituted authorities. This certification applies to the original license and/or
registra on and any renewals thereof.
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Auth ized Signature Date
CITY OF BLA R
CONTRACTOR REGISTRATION ACT
EXEMPTION CERTIFICATION
Date:
According to the exemptions authorized in the Contractor Registration Act (Nebraska Statute §48-
2101 to 48-2117), I hereby certify that the Contractor indicated below is exempt from registering as
a contractor under the Contractor Registration Act for the following reason(s):
❑ The contractor:
1. Is not engaged in the business of the construction, alteration, repairing, dismantling, or
demolition of buildings, roads, bridges, viaducts, sewers, water and gas mains, streets,
disposal plants, water filters, tanks and towers, airports, dams, levees and canals, water
wells, pipelines, transmission and power lines, and every other type of structure, project,
development, or improvement within the definition of real property and personal
property, including such construction repairing or alteration of property to be held
either for sale or rental.
2. Only performs construction work on property which is owned, leased or rented for their
use.
❑ The contractor earns less than $5,000 annually for construction services.
Contractor Name:
Mailing Address:
Applicant Signature:
Applicant Name (printed):
Title:
S:\Building Dept. Forms\Labels\Contractor Registration Renewal-
Letters\DOL Contractor Exemption Certificate.docx