GM Registration 2010.tif I
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FOR OFFICE USE ONLY
CITY OF BLAIR 1521
218 S. 16TH STREET Date Paid: d, 0
BLAM, NE 68008 Receipt No: � e° U
(402) 426 -4191
FAX (402) 426 -4195 Date Issued:
email: CityofBlair@huntel.net BOND EXPIRES:
q Promise ° (Continued)
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CONTRACTOR REGISTRATION / LICENSE RENEWAL
Verify the following information:
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Business Name: G.M. Heat & Air Conditioning
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Address Michael Borowiak
350 Midland #396
Syracuse, NE 68446
Phone # 402 297 6 545
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Mobile # 402 297 6 545
Number of Employees: 5 Journeymen: 3 Apprentices: 2
Type of Business: Mechanical
Other Licenses Held: Lincoln, Seward (Masters)
Insured? No Worker's Compensation? No
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Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Bond Expires Amount
Michael Borowiak Master Heater (Fremont Heaters 7/23/2010 $60.00
List additional license / registrations:
Name License / Registration Bond Expires Amount
Please submit a copy of your
current City of Fremont License
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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 nd obey all order, requirements and regulations of its lawful
constituted authorities.
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Author ed gnature Date
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