Luxa Registration 2011.tif i
FOR OFFICE USE ONLY
- CITY OF BLAIR 22 � o
218 S. 16TH STREET Date Paid:
BLAH2, NE 68008 Receipt No: o? I U a 5
(402) 426 -4191
Date Issued:
FAX (402) 426 -4195 b "
a o ° email: CityofBlair @huntel.net BOND EXPIRES:
0
(Continued)
'� promise �-
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Verify the following information:
Business Name: Luxa Construction Company, Inc.
Address Mike Luxa
925 East Dixon Load
P.O. Box 105 j
Blair, NE 68008
Phone # 402 - 426 -2 778
Mobile # 402 510 8 200
Number of Employees: DSO .?o Journeymen: 0 Apprentices: 0
Type of Business: General Contractor
Other Licenses Held:
Insured? Yes Worker's Compensation? Yes
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration e L' LLP�O Amount
K Mike Luxa General Contractor 08/01/2011 $60.00
List additional license /registrations:
Name License / Registration Amount
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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 and obey all order, requirements and regulations of its lawful
constituted authorities. /%�
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Authorized Signature Date