USM Registration 2022CITY OF BLAIR
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: o
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
❑ Electrical Contractor- $60.00
❑ Gas Line Installer- $25.00
Mechanical Contractor - $60.00
❑ Plumbing Contractor - $60.00
Business Name:
Applicant Name:
Business Address: f City:
Mailing Address: City.
Email Address:_
Phone #:
❑ Tree Trimmer - $60.00
❑ Drain Layer - $60.00
❑ Fire -Security System Installer -$25.00
❑ Water Service Line Installer - $60.00
MENA" WNW State:
State:
Zip:
Business Address outside of Nebraska:
City:
Contact Person:
State
Number of Employees: Apprentices:
Other Licenses Held:
Zip: Phone:
Journeymen:
Insurance/Worker's Compensation Company:
Electrical, Gas Line Installer, Mechanical, Plumbing Contractors and Tree rimmers 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
copy of your Nebraska State License.
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 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. 1 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 therepf.
Au Si nre •' Date
CITY OF BLAIR
218S.16 1h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair@ci.blainne.us
FOR OFFICE USE ONLY
Date Paid:
Receipt No:
Date Issued:
BOND EXPIRES:
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink — if you need more space, please attach additional sheets)
Application is four:: Journeymen/Apprentice - $25.00 each
Business Name. U11 ,5 .
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Master's Name: 0,
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Business Address: l City:JState: Zip: (p
Phone #: �6� e l 9 / �O� 9 Mobile #: z0b,7- Z ��_
Please List all employees that you wish to register and check the appropriate boxes.
Name Plumber Heater Electrician Apprentice Journeyman
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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.
I 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, requirements and regulations of its lawful constituted authorities. This certification applies to the
original license and/or registration and any renewals thereof.
Au onze a re Date
1/6/22, 8:56 AM Official Nebraska Department of Labor - Contractor Registration - Contractor Details
iD"'etails
Contractor/Subcontractor Name
U.S. Mechanical Service hic.
Corporation Name
Business Entity
Corporation
Address
1209 Royal Dr.
Papillion, NE 68046
City
Papillion
State
NE
Zip
68046
Telephone
(402) 991-2899
Registration Number
38033-21
Registration Expiration
10/15/2022
Sales Tax Option
1
Number of Employees
7
Worker's Compensation Status
Certificate on File
https://dol.nebraska.gov/conreg/Contractor/Details/3803321 1/1