Machine Registration 2012.tif -- ... CITY OF BLAIR FOR OFFICE USE ONLY
218 S 16TH STREET
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BLAIR, NE 68008 Date Paid: °� —
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(402) 426 - 4191 Recei t No:
i i x h a* FAX (402) 426 - 4195 Date Issued:
f BOND EXPIRES
Email: cityofblair @ci.blair.ne.us
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
the company /business
Machine Worx Inc. information listed here:
147 Colfax St
Blair, NE 68008
Phone numbers on record:
Type Phone Number: Type: Phone Number:
Office 402 533 8466
Mobile 402 533 8764
Email Address:
Type of Business: General Contractor
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Robert W. Burt General Certificate of Liability 12/19/2012
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
❑ Robert W. Burt 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 obey all order, requirements and regulations of its lawful constituted authorities.
Authorized Signature Date
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