JTech Registration 2022CITY OF BLAIR
218S.16 1h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraslca.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 ❑ Wafer Service Line Installer- $60.00
❑ Plumbing Contractor- $60.00
Business Name: C��Sf�✓G��vn l�G
Applicant Name:_ZICA J V'4'-((
Business Address: 4/11061- 1&wnham .Ave.- City: nr-0/.- State: /UL-- _ zip:
Mailing Address: �% '� (-fie-14A il.t- City: L4' ea- State: /V Zip: g�-U ;7 -
Email Address: ' ?1r:K-k C"a a Co/" .
Phone #: Fax #: Mobile #.-q&) -fao
Business Address outside of Nebraska:
City:
State
Contact Person: Zr h 13,vn11
Zip: Phone:
Number of Employees: 50 Apprentices: Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company: AGvr'
I
Electrical, Gas Line Installer, Mechanical, Plumbing Contractors and Tree Trimmers 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.
enera . oritractors need to sabmit a Certificate of lnsurance'vtintii irriinirnu>n hm�ts of 1 000,000 Aggregatef $300;000 each
occurrence'viirth tine ceri ificate Milder b6iiig tii6 :.bty 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 I5 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 saidwocation. 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
/6 2O7 -L
uthorize lgnature Date
5/19/22, 3:50 PM Official Nebraska Department of Labor - Contractor Registration - Contractor Details
Contractor Details
Contractor/Subcontractor Name
J -TECH CONSTRUCTION
Corporation Name
J -Tech Construction
Business Entity
LLC
Address
6200 Havelock Ave
LINCOLN, NE 68507
City
LINCOLN
State
NE
Zip
68507
Telephone
(402) 261-3682
Registration Number
36130-21
Registration Expiration
12/15/2022
Sales Tax Option
2
Number of Employees
40
Worl<er's Compensation Status
Certificate on File
https:Hdol.nebraska.gov/conreg/Contractor/Details/3613021 1 /1