USM Registration 2014.tif CITY O F B LAIR FOR OFFICE USE ONLY
218 S 16TH STREET
Bate Paid:
! BLAIR, NE 68008 �(p0
i Receipt No:
(402) 426 - 4191
r FAX (402) 426 - 4195 Date Issued
BOND EXPIRES — -
Email: cityofblair @cLialairmems
CON TRACTOR REGISTRATION / LICENSE RENEWAL
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Please verify and correct
the company business
US Mechanical Service Inc. information listed here:
1209 Royal Dr
PAPILLION, NE 68046
Phone numbers on record:
Type: Phone Number: Type: Phone Number:
office 402- 991 -2699
I
Mobile 402 - 657 766QO
Email Address: (2 C�/ 1 f Plea uai a �oPy o yon
current i o f Bellevue License
Type of Business: MECHANICAL
Please submit new reciprocating license for those which have expired:
Name Reciprocating License Expires
Labs, Craig
Bellevue Mechanical License 12/31/2013
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires ir. ViC
Labs, Craig Mechanical Bond 3/1/2013 V 1
-- yy AA
Place a check in the box next to the licenses you wish to renew: -;Cr
Renew? Name License / Registration Expires Am nt aoj
12/31/2013 $25, �(
House, Dan Journeyman Mechanical
C6—
_ Labs, Craig Mechanical Contractor 12/31/2013 $60 r k y r
Nissen, John Journeyman Mechanical 12/31/2013 $25
ent ee �9 c is ~��
i/ � y..• �° " se . , ike ,.w_� AppL�, `.
Totusek, Andrew Apprentice Mechanical 2/31'2013 $25
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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 and obey all order, requirements and regulations of its lawfu constituted authorities.
Authq ize Signature Date