Corbion Registration 2022-"Omise of a``
CITY 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: — 2 - ",EZ
Receipt No:' 1
Date Issues:
BOND EXPIRES:
CONTRACTOR REGISTRATION / LICENSE RENEWAL
CORBION Please verify and correct the
company /business
650 S IND PARK DR Information listed here:
BLAIR NE 68008
Type of Business: CONTRACTOR LICENSE
Contact information on record:
Type:
Phone Number: Type: Phone Number:
Work
(402)426-0377 Fax (402)533-8205
Cell
(402)332-9667
Email Address:
J.WEIDES CORBION.COM
Please submit a current reciprocating license and NDOL or those which have expired.-
Name:
x ired;Name: ReciprocatingLicense: Expires:
CORBION EXEMPT
Please submit new certificates or bond renewals.for those which have expired;
Name:
Certificate of Liability or Bond:
Expires:
CORBION
GENERAL
1/01/2021
Place a check in the box next to the licenses you wish to renew.-
Renew?
enew:
Renew? Name: License / Registration: Expires: Amount:
CORBION CONTRACTOR LICENSE 1/01/2022 60.00
CI'T'Y OF BLAIR
CONTRACTOR REGISTRATION ACT
EXEMPTION CERTIFICATION
Date: T -7(;7,Z,
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:
'1r TT
S:ABuilding Dept. Forms\Forms\DOL Contractor Exemption Certificate.