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Noodle Registration 2012.tif i FOR OFFICE USE ONLY CITY OF BLAIR Date Paid: 218 S. 16 Street Receiptue Date Issued: Bla ir, CIE 68008 BOND EXPIRES: (402) 426 4191 FAX: (402) 426 4195 Email: cityofblair @ci.blainne.us Application is: XNew El Renewal CON TRACTOR 1ST I /LI L (Please type or print in ink — !", need more space, please attach additional sheets) Application is for: Con tra ctor E $60.00 ❑ Electrical Contractor - $60.00 ❑ Water Service 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 I Business Name: N00 bLC P o©`bl F � oor. DADS �r,r Applicant Name: Business Address: (a I �VRS�'�n City: State: Zip: 00 Phone #: �`1��� ` 015 Fax #: Mobile #: Business Address outside of Nebraska: City: I -'/ A State LI Zip: ` Phone: Contact Person: Number of Employees: / Apprentices: � Journeymen: i Other Licenses Held: Insurance/Worl<er's Compensation Company: 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. 1 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. This certification applies to the original license and /or registration and any renewals thereof. Author eo gnatur ` Date