PowerS Registration 2012.tif CITY OF RLAIR FOR OFFICE USE ONLY
. 218 S 16TH STREET
RLAIR, NE 68008 Date Paid: - o l
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(402) 426 - 4191 Receipt No:
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` .V, FAX (402) 426 - 4195 Date Issued:- -
i - co cityofblair @ci.blair.ne.us BOND EXPIR
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
the company /business
Power Solutions Electric Co. Inc. information listed here:
6013 N 167th Terrace Piz
OMAHA, NE 68116
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Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Office 402 6813746
Mobile 402 957 4302
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Email Address: r �
Type of Business: General
Please submit new reciprocating license for those which have expired:
Name Reciprocating License Expires
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Jason M. Brown Electrical State Card 12/31/2012
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Jason M. Brown Electrical Bond 9/7/2012
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
Jason M. Brown Electrical Contractor 12/31/2011 $60
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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 nd obwy all order, requirements and regulations of its lawful constituted authorities.
4 , A tze Si ature Date LLLJ��
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