MidlandU Registration 2011.tif i
FOR OFFICE USE ONLY
Date Paid: �� '�
218 S. 16 th Street Receipt No: °' � —
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair@ci.blainne.us
Application is: ❑ New ® Renewal
C REGISTRATIO R ENEWA L
(Please type or print in ink — If you need more space, please attach additional sheets) j
Application is for: ❑ Contractor - $60.00 ❑ Electrical Contractor - $60.00
F Water Service Line Installer - $60.00 ❑ Tree Trimmer - $60.00
❑ Fire /Security System Installer - $25.00 ❑ Gas Line Installer- $25.00
❑ Mechanical Contractor - $60.00 ❑ Plumbing Contractor- $60.00
Drain La - $60.00 �
Business Name: j/
Applicant Name:
Business Address: J 2 � �� � City ;l' State: �'(- Zip: -?C
Phone #: 5 � Fax #: Ve 2 5 -2 2 ���( Mobile #:
Business Address outside of Nebraska:
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City: State Zip: Phone: j
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Contact Person:
Number of Employees: Apprentices: Journeymen:
Other Licenses Held: 0 k k9d <��✓ `� J� /��
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Insurance/Worker's Compensation Company:
Drain Layers /Electrical, Plumbing and Mechanical Contractors/Water Service Line Installers need a $5,000 permit bond in favor
of the City of Blair. Tree Trimmers need a $5,000 permit bond 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.
All information contained in this application is true and correct. 1 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 obey all order, re%firements and regulations of its lawful constituted authorities. This certification applies to the
original I" nse and g and any renewals thereof.
Au horized Signat Date