Jorgensen Registration 2010.tif OF Y FOR OFFICE USE ONLY
CITY 1 L 20
218 S. 16TH STREET Date Paid:
BLAIR, NE 68008 Receipt No:
402 426 -4191
Date Issued:
FAX (402) 426 -4195
aE Q o ° email: CityofBlair@huntel.net BOND EXPIRES:
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CONTRACTOR REGISTRATION / LICENSE RENEWAL
Verify the following information:
Business Name: Jorgensen Contracting, Inc.
Address Gerald P. Jorgensen
530 Front Street
Blair, NE 68008
Phone # 402 - 426 -4 440
Mobile #
Number of Employees: Journeymen: Apprentices:
Type of Business: General Contractor
Other Licenses Held:
Insured? Yes Worker's Compensation? Yes
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration I Cert ificate of Liability Expires Amount
❑ Gerald P. Jorgensen General Contractor 1/1/2010 $60.00
List additional license / registrations:
Name License / Registration Bond Expires Amount
YOUR CERTIFICATE OF LIABILITY
INSURANCE IS EXPIRED OR ABOU
TO EXPIRE. PLEASE SUBMIT A NEW
COPY WITH YOUR RENEWAL
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 oey all order, requirements Ind regulations of its lawful
constituted authorities
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