TotalC Registration 2011.tif I
CITYOF BLAIR FOR OFFICE USE ONLY
Date Paid:
®II -11 '
218S.16 1h Street Receipt No 2 i3 7q I
Date issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cittofflalr@d.blainne.us
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: ® Contractor- $ 60.00 ❑ Electrical Contractor- $60,00
n .Water Service Line Installer- $60.00 ❑ Tree Trimmer- $60.00
❑ Fire /Security System Installer- $25.00 ❑ Gas Line Installer - $2100
❑ Mechanical Contractor- $60.00 ❑ Plumbing Contractor -$60.00
❑ Drain Layer- $60.00
Business Name: Total Construction Services Inc.
Applicant Name: Kevin Jackson
Business Address: 6727 N. 56th St. City: Omaha State NE— Zip: 68152
Phone #: 402 - 572 -7457 FaX #: 402 - 572 -0226 Mobile #: 402 - 306 -0340
Business Address outside of Nebraska
City: State Zip: Phone:
Contact Person: Kevin P Jackson
Number of Employees: 25 Apprentices: Journeymen:
Other Licenses Held:
insurance/Worker's Compensation Company: Allied Insurance
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 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 IS days of the change.
1 hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 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 registrat nd any renewals thereof.
on ed Signature Date
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