Natureworks Registration 2012.tif I
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a CITY OF BLAIR FOR OFFICE USE ONLY
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r' 218 S 16TH STREET
BLAIR, NE 68008 Date Paid: _
-. (402) 426 - 4191 Receipt No: , a
{.� FAX (402) 426 - 4195
Date Issued:
f F ' BOND EXPIRES
Email: cityofblair @ci.blair.ne.us _
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
NatureWorks LLC the company /business
information listed here:
650 Industrial Park Dr dd
Blair, NE 68008
Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Office 402 533 1400
Office 402 533 1422 ffO2 f 33 -14W,6
Email Address: a.co�
Type of Business: General
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Dennis Bravo General Certificate of Liability 12/1/2011
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
Dennis Bravo 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
ca ion and obey all order, requirements and regulations of its lawful constituted authorities.
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>2 -2 7 -X0
Authorized Signature Date
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CITY BLAIR FOR OFFICE USE ONLY
Date Paid: (0 — t� '
218 S. 16th ii
Street Receipt NO: ��,' '
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair@ci.blainne.us
Application is: New ❑ Renewal
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CON TRACTOR IT TI /LIC S L
(Please type or print in ink — If you -need more space, please attach additional sheets)
Application is for: Contracto - $60.00 ,.• ❑ Electrical Contractor - $60.00
r O Water Serviitd- Line'Installer - $60.00 ❑ Tree Trimmer- $60.00
❑ Fire /Security System Installer- $25.00 ❑ Gas Line Installer- $25.00
❑ Mechanical Contractor- $60.00 ❑ Plumbing Contractor- $60.00
❑ Drain Layer-$60.00
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Business Name:
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Applicant Name: t� L 1 t S Jrc� �f 0
Business Address: 1" d r . City: e ir State: zip: Q
Phone #: 33.. AtI Fax #: 3 `" ! 0 r Mobile #:
Business Address outside of Nebraska: l
City: A) to i\ Al i ca State � Zip: 5� 3 Yom` Y Phone: ye) 10
Contact Person:
Number of Employees: Apprentices: Journeymen:
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Other Licenses Held:
Insurance/ Worker's Compensation Company: !Jh s ��_ l �r -o ir
Drain Layers /Electrical, Plumbing and Mechanical Contractors/Water Service Line Installers need a $5,000 permit bond in favor
of the City of Blair. Tree Trimmers need a $5,000 permit bond in favor of the City of Blair. Electrical Contractor and Fire
Security Systems Installer will need to submit a copy of your Nebraska State License.
General Contractors need to submit a Certificate of Insurance with minimum limits of $1,000,000 Aggregate /$300,000 each
occurrence.
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 1 am competent and experienced to
engage in above said vocation. 1 agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocatpRand obey all order, requirements and regulations of its lawful constituted authorities. This certification applies to the
on nal li ense and /or registration and any renewals thereof.
Authorized Signature Date