NebraskaH Registration 20233/2/23, 11:20 AM
Mail - Building Department - Outlook
crry OF BLAIR
218 S 161h Street
Blair, NE 68009
(402) 426-4191
Fax (402) 426-4195
Fnnail: building'u blairilel-iraska.org
FOR OFFICE. USE ONLY
1 7 Date Paid: ry -)(0
Receipt No:
Date Issues:
BOND EXPIRES:
CONTRACTOR REGISTRATION / LICENSE RENEWAL
NLBR_ASKA. 14ANDYNIAN
1500 ADANIS ST
BLAIR NE 68008
Type of Business: CONTRACTOR LICENSE
Contact information nn record:
Please verif y and correct the
coinitanY 1hushress
Inforinatloit listed here:
Type:
Phone Number:
Type:
Phone Number:
Work
(.402)719-7219
Fax
Cell
Email Address:
JASON (CvN E BRASKA HAN DYMAN.CONI
Pleci.se submit q current recipt-octithw ficensefin- those which will or have LV_L)ire(
Name: I ReeiDrocafinp License:
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Pleave submit new certificates w hond)-enew(jb cind ADOL for those which will or htive ex: ire&
Name: Certificate of Liability' or Bond: rN - --------- L—pir—
NEBRASKA HANDYMAN CiENERAI, 1 811 r202 3
NEBRASKA HANDYMAN I NDOI. 3/0112023
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Renew?
Name:
NEBRASKA I IANDYN1AN
License / Reuistration-
CONTRACTOR LICU'NSF
Ex sires:
1 /0 1 Q1023
Amount:
60.00
0
0
0
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218 S. 161h 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 X Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink - If you need more space, please attach additional sheets)
Application is for: X Contractor- $60.00 ❑ Tree Trimmer- $60.00
❑ Electrical Contractor- $60.00 ❑ Drain Layer- $60.00
❑ Gas Line Installer- $25.00 ❑ Fire -Security System Installer 425.00
❑ Mechanical Contractor- $60.00 ❑ Water Service Line Installer- $60.00
❑ Plumbing Contractor- $60.00
Business Name: Nebraska Handyman
Applicant Name: Jason Crawford
Business Address: 1500 Adams Street city: Blair State: NE zip: 68008
Mailing Address: 1500 Adams Street City: Blair State: NE zip: 68008
Email Address: Jason@nebraskahandyman.com
Phone #: 402-719-7219 Fax #: Mobile #:
Business Address outside of Nebraska
City:
Contact Person
State
Jason Crawford
Number of Employees: 1
Other Licenses Held:
none
zip:
Apprentices: 0
Insurance/Worker's Compensation Company: Contractors Liabil
Phone:
Journeymen:
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.
i 3/01/2023
Authorized Signature Date
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