City Registration 2010.tif FOR OFFICE USE ONLY Sj(D
CITY OF BLAIR 67
218 S. 16TH STREET Date Paid: , ' 00
BLAIR NE 68008
1' � Receipt No:
(402) 426 -4191
FAX (402) 426 -4195 Date Issued:
61 email: CityofBlair @huntel.net BOND EXPIRES:
4
A promise o (Continued)
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Verify the following information:
Business Name: City Wide Heating & A/C Sys. Inc.
Address
P. O. Box 308
Waterloo, NE 68069 -0308
Phone # 402 - 330 -3 120
Mobile # 402 289 4 822
Number of Employees: 10 Journeymen: 7 Apprentices: 2
Type of Business: Mechanical
Other Licenses Held: Oma
Insured? No Worker's Compensation? No
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Bond Expires Amount
❑ Donald Drakulich Journeyman Heater $25.00
❑ David Kresl Journeyman Heater $25.00
Brad Butcher Journeyman Heater $25.00
Rick Lochmiller Residential Heate 12/14/2010 $60.00
Paul Gargarella Journeyman Heater $25.00
List additional license / registrations:
Name License / Registration Bond Expires Amount
Nb
0
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 obey quirements and regulations of its lawful
constituted authorities.
Au horized ignature Date