Corbion Registration 2023CITY OF BLAIR
218 S 161" Street
Blair, NE 68008
(402) 426-4191
Fax (402) 426-4195
Email; building@blalrnebraska•org
%•OR OFFICE USE ONLY
DatePaid;?- —IWd
Receipt No;
Date Issues;
BOND EXPIRES;
CONTRACTOR REGISTRATION / LICENSE RE' NEWAL
01/1! CORBION
650 S IND PARK DR
BLAIR NE 68008
Type of Business: CONI'IUCTOR LICENSE
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company / bushiess
Informallon 11slerl here.,
Ty p e:
Phone Number:
T e:
Phone Number:
Work
402 426.0377
Fax
402 533-8205
Cell
402 3.32-9667-
Email Address: :-3,WEIDES
CORBI0MC0M , '! r.`�.9"rl '
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Natue:
Recl i ocating License:
Ex ices:
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Name:
Cevtifiente of LIHAity or Bond:
Expires:
CORBION
GENERAL
1 /01 /2022
CORBION
NDOL -; - (..), :� �j ;= j� .1
EXEMPT
Al: �lo:�r.yr';,�:)hn.'.h'r., .»ni7 7n tho:arnni�rn.r yin�i y:Uirb 4n'i hat.i i•
Renew?
Name:
License / Re istration:
`Ex lres:
Amount:
CORBION
CONTRACTOR LICENSE
1/01/2023
60.00
❑
❑
Ray this amount: 60.00
Please list an) additioncll licenses or 1 e tsh,01ons;
Name. Tlicenses a ish'ntiont Amounts
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and
experienced to engage in the above said vocation,
I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said vocation and obey all
orders, requirements and regulations of its lawful constituted authorities,
I also certify that all information contained in this application is true and correct, I will notify the City of Blair
of any changes hi the information reported on or with this application form within 15 days of any change,
Authorized Signature
Date
CITY OF BLAIR
EXEMPTION CERTIFICATION
Date: - '"% 7 ,.
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:
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.
A The contractor earns less than $5,000 annually for construction services.
Contractor Name:
Mailing Address:
:Y
Applicant Signature:
Applicant Name (printed):r1L't L ,-C7�
Title:psr.-
S:ABuilding Dept. F ms\Forms\DOL Contractor Exemption Certificate.doc