CustomCo Registration 2023CITY OF B❑AIR
218 S. 1611 Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebrasica.org
FOR OFFICE USE ONLY
Date Paid:
Receipt No:
Date Issued: °
BOND EXPIRES:
34
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: W Contractor- $60.00
❑ Electrical Contractor- $60.00
❑ Tree Trimmer- $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
❑ Plumbing Contractor- $60.00
Business Name: Custom Concrete Designs
Applicant Name:
Business Address: 1804 Paul St
City: Omaha State: NE Zip: 68102
Mailing Address:
City: State: Zip:
Email Address:Jake@ccdentomaha.com
Phone #: 402-896-1497 Fax #:
Mobile #: 402-699-4919
Business Address outside of Nebraska:
City: State Zip:
Phone:
Contact Person:
Number of Employees: Apprentices:
Journeymen:
Other Licenses Held:
Insurance/Worker's Compensation Company:
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
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.
Authorized Signature
Date
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