CustomCo Registration 2024CITY OF BLAIR
218 S 161h Street
Blair, NE 68008
(402) 426-4191
Fax (402) 426-4195
Email: building@blaimebraska.org
FOR OFFICE USE ONLY
Date Paid: ` 411
Receipt No: i X:' 1,
Check # or CC:
Amount Paid: t "')
CONTRACTOR REGISTRATION / LICENSE RENEWAL
CUSTOM CONCRETE DESIGNS Please verify and correct fire
compazty / bzzsiztess
1804 PAUL ST Infon ration lister! )sere:
OMAHA NE 68102
Type of Business: CONTRACTOR LICENSE
Contact information on record:
Type-
Phone Number:
Type:
Phone Number:
Work
402 896-1497
Fax
Cell
- L,
Email Address:
CCDENTOMAHA.COM
Please submit a current reciprocating license for those which will or have expired:
Name: Reciprocating License: Expires:
Please submit new certificates or bond renewals and NDOL for those which will or have expired. -
Name:
Certificate of Liability or Bond:
Expires:
CUSTOM CONCRETE DESIGNS
GENERAL
11/09/2023
CUSTOM CONCRETE DESIGNS
NDOL
8/15/2023
Place a check in the box next to the licenses you wish to renew. -
Renew,?
Name:
License / Registration:
Expires:
Amount:
CUSTOM CONCRETE DESIGNS
CONTRACTOR LICENSE
1/01/2024
60.00
Pay this amount: 60.00
Please list any additional licenses or registrations..
Name: I License / Re istration: Amount:
I hereby make an 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 in the information reported on or with this application form within 15 days of any change.
Authorized gignature Date
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