Luxa Registration 2012.tif i
CITY OF BLAIR FOR OFFICE USE ONLY
218 S 16TH STREET
BLAIR, NE 68008 Date Paid : /
- (402) 426 - 4191 Receipt No:
*:,° FAX (402) 426 - 4195 Date Issued:
� is Email: cityofblair @ci.blair.ne.us BOND EXPIRES
CONTRACTOR REGISTRATION / LICENSE RENEWAL
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Please verify and correct
the company /business
Luxa Construction Company, Inc. information listed here:
925 E Dixon Rd dd
Blair, NE 68008
Phone numbers on record:
Type: Phone Number: Type: Phon Number:
Office 402 - 426 -2778 !
Mobile 402 510 8200
Email Address:
Type of Business: GENERAL
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Mike Luxa General Certificate of Liability 8/1/2011
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
Mike Luxa General Contractor 12/31/2011 $60
Please ... list any additional license or 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 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 bey II or er, requirements and regulations of its lawful constituted authorities.
Aut orized Signatu Date
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