BossE Registration 2023CITY OF BLAIR
218 S. 16th Street
Blair, NE 68008
FOR OFFICE USE ONLY
Date Paid: Pad, 3
Receipt No: _ I!
Date Issued: I � 4 '
BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195 i
Email: building@blairnebraska.org
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 ❑ Water Service Line Installer- $60.00
r❑ Plumbing
g Contractor- $60.00
Business Name: '' 0 SS L-1 &,C-4V:C, I rlx,4t-lG�l irIc
Applicant Name:L
Business Address: �� 2 Oj S �( �ST City: O i,� c, k State: A J r- Zip: (e I Z
Mailing Address: s'c, w, P. c.s-- c-A 6"if City: State: Zip:
Email Address: Co, *k", bt-s P rx4gbo t
Phone #: LJQ2' (r 0-- ZS93 Fax #: Mobile #:
Business Address outside of Nebraska:
City: State Zip: Phone:
Contact Person:
Number of Employees: _ 2 Apprentices: Z Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company: S4-I14 f EG vwn
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.
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.
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. 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 thereof.
Aut ed Signature Date
CITY OF BLAIR
218 S. 1 Gth Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebrasl(a.org
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 for: Journeymen/Apprentice - $25.00 each
Business Name: B o 5-5 c, at, 4'vs r=tee
Master's Name: ZC..c �� ��r,(r-- r P
Business Address: S � �'�� . J) City: �'�State: _Ajt Zip:
Phone #: � Y-? ) Mobile #: Sa 2
11 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. 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.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I 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.
OZ I f 202 3
74ed Signature Date
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