Boldens Registration 2010.tif May. 4, 2010 3:53PM CITY OF BLAIR (402. 426. 4191) No, 4542 P. 2
CITY BLAIR FOR OFFICE USE ONLY
Date Pald: J lr ()
2 th Str eet Recelpt N
Date Issued: -
Blair, NE 68008 BOND EXPIRES
(402) 426 4191 FAX: ( 426 41
Email: cityoffilair@dblair.ne.us El
Application is: New Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in inlc - if you need more space, please attach additional sheets)
Application is for: G7 contractor- $60.00 ❑ Electrical Contractor- $60.00
❑ Water Service Line Installer- $60.00 [] Tree Trimmer- $60.00
Fire /Security System Installer- $25.00 ❑ Gas Line Installer- $ 25.00
El Mechanical Contractor- $60.00 ❑ Plumbing Contractor- $60,00
'* Drain Layer - S 60 .00
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Business Name:
Applicant Name: A 4 zgode �.
Business Address , City: '✓' / State: �Ip: ✓��
Phone #: � - e ?53 Fax #: �� ��/ ° J��� Mobile 0: O,� ° X2 �' " � Ile
Business Address outside of Nebrasica:
City: State ZIP: Phone.
Contact Person
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Number of Employees: Apprentices: % Journeymen: , B
A) 4hraaj eL Q,"
Other Licenses Held( r e Via. 5 •o.:r r e- Ia. s i � u ° /�� ' �� /l�
Insurance/Wori(er "s Compensation Company: �j:,a S ,. , tl 0 J 0 h)61,. T n Cap>
GUiv%�• �j Ctr'
Drain Layers /Electrical, Plumbing and Mechanical Contractors/Water Service Line Installers need a $5,000 permit Fo rd in�vor
of the City of Blair. Tree Trimmers need a $5,000 permit bond in favor of the City of Blair. FlectAcal 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 S 1,000,000 Aggregate /$300,000 each
occurrence.
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 Hiair, 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 Signature Date