PremierEx Registration 2024CITY OF BLAIR
218 S. 161h Street
Blair, NE 68008
(402) 426 4191 FAX: (402) 426 4195
Email: building@blairnebraska.org
FOR OFFICE USE ONLY
Date Paid: q 9 --dW
Receipt No: _, " 0':�`
Date Issued:
BOND EXPIRES:
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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: .0 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: ��i`_'iY1 f --:&5 a/ s_z'1 G
Applicant Name: -:I Ayv\e. sr l r
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Business Address: 13 5 � �'D� sC� o 0e �. � -j /� City: (32m✓J aq State: Zip: ej,13 J
Mailing Address:---- S,��i �x Y� 5 j :;, 61/� City: State. Zip.
Email Address: L1 /m 6 ,� -L—n LA (CAW ZY4 , C 6,8
Phone #: Fax #: IV . Mobile*:
Business Address outside of Nebraska:
City: State Zip: Phone:
Contact Person:
Number of Employees:
Other Licenses Held:
Apprentices:
Insurance/Worker's Compensation Company:
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 I S days of the change.
1 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 Signat-Dr4 Date
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