USM Registration 2013.tif i
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CITY OF BLAIR
FOR OFFICE USE ONLY j
Date Paid:
2 18 S. 1 6 th Street Receipt No L
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair @ci.blair.ne.us
Application is: ❑ New enewal
CONTRACTOR REGI TR °TI /LIC L
(Please type or print in ink — if you need more space, please attach additional sheets)
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Application is for: Contractor - $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
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❑ Mechanical Contractor - $60.00 ❑ Plumbing Contractor- $60.00
❑ Drain Layer - $60.00
Business Name:
Applicant Name:
Business Address: K M City: state Zip:
Phone #: f ° Fax #: I® Mobile #: w ��
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Business Address outside of Nebraska:
City: State �LL Zip: Phone:
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Contact Person: ro-t
Number of Employees: Apprentices: Journeymen:
Other Licenses Held:
insurance /Worker`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 isam competent and experienced to
engage in above said vocation. l 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.
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utho ' ed Signature Date
CITY OF BLAIR
FOR OFFICE USE ONLY f
Date Paid: ®� g
218 S. 16 Street Receipt No:
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cit ofblair@ci.blair.ne.us
CON TRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink -- If you need more space, please attach additional sheets)
Application is for: Journeymen/Apprentice-$25.00 each
Business Name: S.
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Master's Name:
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Business Address: 4 Of- Cifiy: i State: Zip:
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Phone #: 4 / 0 0 2 7 l ® Mobile #:
Please List all employees that you wish to register and check the appropriate boxes.
Name Plumber Heater Electrician Apprentice Journeyman
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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 75 days of the change.
1 hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 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.
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Autqpf Signature Date
01102/2013 15:50 4029913975 US MECHANICAL SERVIE PAGE 01/06
CITY OF BLAIR i FOR OFFICE USE ONLY
218 616TH STREET
BLAIR, NE 68009 Date Paid:
(402) 426 - 4191 Receipt No:-
Date Issued:
FAX (402) 426 - 4195 EQIUD EXPIRES
Q Email: cityof`bIalr0MeLbIai1r.ne.us
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CONTRACTOR REGISTRATION LICENSE RENEWAL
Please verify and correct
the company /business
US Mechanical Service Inc. I - information listed here.
1209 Royal Dr
PAPILLION, NE 68046
Phone numbers on record;
Type: Phone Number: Type: Phone Number;
Office 402-9912899
Mobile 402-657-6600
Email Address:
Type of Buflness: MECH0
Ple-ases,ubmit•n c e
.ew r tip�qtg4.orhond. renoWqI4 fpr. �4 which hlxpired
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Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration i Expires Amount
❑ House, Dan Journeyman Mechanical 12/31/2012 $25
❑ Labs, Craig Mechanical Contractor 12/31/2012 $60
❑ Nissen, John Journeyman Mechanical l 12/31/2012 $25
Sorensen, Mike Apprentice Mechanical i 12/31/2012 $25
Please list any additional license or registrations
Name License / Registration i Amount
------------------------ - - - - -- — -------- - - - - -- – ------------ - - -- – ------------------- – ----------- – --
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All Information contained in this application is true and correct. I will not . #y the City of Blair of any chzinges in the
Information reported on or with this application form within 15 days of c ange.
I hereby make application to the Licensing Board of Blair, Nebraska and �ertify that I am competent and experienced to
engage In above said vocation. I agree to conform strictly to the Ordlnan�es of the City of Blair, N'etraska relative to said
vocation a nd obey all order, requirements and regulations of its lawful constituted authorities.
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