Jorgensen Registration 2022"0")wse of 0�"
CITY OF BLAIR
218 S I61h Street
Blair, NE 68008
(402) 426-4191
Fax (402) 426-4195
Email: building@blairnebraska.org
FOR OFFICE USE ONLY
k
Date Paid:
Receipt No:
Date Issues: :
BOND EXPIRES: t ��
CONTRACTOR REGISTRATION / LICENSE RENEWAL
JORGENSEN CONTRACTING INC
530 FRONT ST
BLAIR NE 68008
Type of Business: CONTRACTOR LICENSE
Contact information on record:
Please verify and correct the
company / business
Information listed here:
Type:
Phone Number:
T e:
Phone Number:
Work
Fax
Cell
402 533-3165
Email Address:
Please submit a enrrent reri"mratino, lirPn.PP n'nd NT)nT. My thnro ivhirh hm)a avnipad-
Name:
Reciprocating"License:
Expires:
JORGENSEN CONTRACTING INC
NDOL
1/01/2022
Please submit new certificates or bond renewals for those whirh hava axningd -
Name:
Certificate of Liability or Bond:
Expires:
JORGENSEN CONTRACTING INC
GENERAL
1/01/2022
Place a check in the box next to the licenses you wish to renew'
Renee .
Name:
License / Registration:
Expires:
Amount:
JORGENSEN CONTRACTING INC
CONTRACTOR LICENSE
1/01/2022
60.00
Please list anv additional licenses or
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and
experienced to engage in the above said vocation.
I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said vocation and obey all
orders, requirements and regulations of its lawful constituted authorities.
I also certify that 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 any change.
Aii orized re Date
C
N
N
C
W
0)
M
0
w
c�
z co
C.4
�OZ
O U
W C m
Z
W W
C 0
�O
0
0
n
c�
J
y.-
O
N
G
e O
E
E
O
46
U)CD
acorn
4i (D tD CM
N
-C Z
d1s O C 1-
(n O11
o U N
�Y Lt7 E O
Z Lc) JIT