GA Registration 2023CITYOF BLAIR FOR OFFICE USE ONLY
Date Paid: t _ ' J
218 S. 16 Street Receipt No:Ci-IC::!�)CL
Blair NE %$®®$ Date Issued:
BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195 3
Email: building@blairnebraska.org
Application is: ❑ New ® Renewal
CONTRACTOR REGISTRATION/LICENSE RENL
(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
❑ Plumbing Contractor - $60.00
Business Name: G.A. West & Co., Inc.
Applicant Name:.G.A. West & Co., Inc.
Business Address: N/A City: State: Zip:
Mailing Address: 1200 Radcliff Road City: Creola State: AL Zip:36525
Email Address: megan.goff@gawest.com
Phone #: 251.410.6266 Fax #: N/A Mobile #: N/A
Business Address outside of Nebraska: 1200 Radcliff Road
City: Creola State AL Zip: 36525 .Phone: 251.679.1965
Contact Person: Megan Goff
Number of Employees: 0 in Nebraska Apprentices: 0 in Nebraska Journeymen: 0 in Nebraska
Other Licenses Held: No other licenses held in Nebraska.
Insurance/Worker's Compensation Company: Carrier - AIG
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 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.
12/21 /2022
Authorized Signature Date
CITY OF BLAIR
1ME 1 A
' -1 1
Date: 12/21 /2022
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: G.A. West & Co., Inc.
. Mailing Address: 1200 Radcliff Road, Creola, AL 36525
Applicant Signature:
Applicant Name (printed): Gary A. West
Title: President