F&B Registration 2013.tif FOR OFFICE USE ONLY
Date Paid: 0 "' ( --
218 S. 1 6 th Street R eceipt No
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: ciWqfblair@d.blair.ne.us
Application is: New ❑ Renewal
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CON TRAC TOR REG ISTRATION/LICENSE RENEWAL
(Please type or print in ink - If you need more space, please attach additional sheets)
Application is for: e Contractor- $60.00 ❑ Electrical Contractor- $60.00
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❑ 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
Business Name:
Applicant Name: �� t w Loeo r
Business Address: j S qy _� 4ppj 5 R, C ! City: State: Zip - 2 - 2
Email Address: I 1 6SeRT - 9 FALL 9 CAN I I ILPO ZS , 6
Phone #: q0 2 - ,� I Z ° � L(3 ® Fax #: 0 - a Z - 0 . Mobile #: q ®Z 57/0 - 23 S-5-
Business Address outside of Nebraska:
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City: — State "® Zip: Phone:
Contact Person: le // �t I L�f ESE !K f
Number of Employees: Apprentices: Journeymen:
C� r1' or O'MAH C /TY elf - '11N6-rL (mac- vii' -5
Other Licenses Held: /
Insurance/Worker's Compensation Company: '� /lv l /�'l l < ti 5 U fZ hN L-
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 deed 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.
Board of Blair Nebraska and certify hat I am c om p etent and hereby make application to the Licensing Board experienced to P P
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.
Authorized Signatu Date
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