Watertight Registration 2014.tif E
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FOR O FFICE USE ONLY j
%CITY OF BLAIR th Date Paid: Street 218 S. 16 Receipt No. ,
Date Issued:
Bla NE 68008 BOND EXPIRES:
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d ( 402) 426 4195
Application is: New ® Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
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(Please type or print in inlc — if you need more space, please attach additional sheets)
Application is for: contractor - $60.00 Electrical Contractor - $60.00
Water Service Lille Installer- $60.00 Tree Trimmer - $60.00
Fire /Security System Installer - $25.00 n as Line Installer - $25.00
❑ Mechanical Contractor- $60.04
Plumbing contractor- G0.00
El Drain La - $60.00
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B us iness Marne: )
A pplicant Name.- r;
Business Address: L - C ity: �.
Email Ad �t�c-�( '�r�' ��J �2,��'�. s C. .
Phone Fax 1 � '� ' , Mobile
usiness Address outside oil Nebraska:
i : State _. Zip: Phone: ' `2,.-u,-o
Contact Person: l
Number of F ployees: Apprentices: Journeymen:
Oth er Licenses Held:
Insura ce/VYbrker's ompensation Company:
Drain Y and Mechanical contractors ater S+er'vice Line Installers creed a S�. 4 permit bond in favor
ers / Electrical, Plumbin 9
of the city of Blair. Tree Trimmers need a $5,000 permit band in favor of the City of lair. Electrical Contractor and Fire
Securi Systems Installer gill need to submit a copy of your Webraska State License.
General Contractors need to submit a Certificate of Insurance with minimum lirmits of 1, 0,000 re ate/ 300,0 0 each
occu nce.
Ali 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 t a days of the change. j
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I hereby snake application to the Licensing Board of Blair, Nebraska and certify that l am competent and experienced to
engage in above said vocation, 1 agree to conform strictly to the Ordinances of the City of glair, Nebraska relative to said
vocation and obey fill order, requirements and regulations of its lawful constituted authorities, This certification applies to the
original license and /or registration an ny renewals thereof.
ed Signature ate
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GENERA CONTRACTOR REGISTRATI
Due to the large number of general contractors seeking roofing and siding work within the
zoning jurisdiction of the City of Blair, the following reference information is required.
References will be checked, so please ensure reference names and phone numbers are
current.
NO WORK S HOULD I TO RECEIVI
A GENERAL CON TRACTOR I T TI .
Three communities in which you are currently registered and have been issued permits:
Community #1 Phone: ( /( -)
Community #2: tc�_l ir° Phone:
L�'� '7 =7
Community #3: r ` �� � �-, Phone: C _
Three personal references for whom you have recently done work:
Client #1 : ell 0 Phone: 4 ' i
Client #2 Phoner__ Z. ) v -�f
Client #3 : 9 Phone:
- -� —
or /Applicant Dat
References verified by: Date
bOiJkYUtai1Y
218 South 16th Street a Blair, Nebraska 68008 402- 426 -4141 ®>=ax 402- 426 -4196 E -mail dtyofblalr @cLblalr.ne,us
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Page 1 of 2
Nebraska Department of Labor
Labor Law / Contractor Registration
550 So. 16 Street
Lincoln, NE 68508
(402) 471 - 2239
Thank you for ret ewing yoz r Contr etor Registration with the Ner` rask.o DepartUnent of Labor,
Print This Page
Ple4@se print this page as your redept.
n 'actaE rifo sake= oil N TI E•< The worker's comp. cer tificate we have on
WATERTIGHT ROOFING file expires on: 04/13/2013. Any contractor whose
3493 CO RD G . records indicate their coverage has expired, will be
TEKAMAH, NE 68061 removed from the list of registered contractors until an
(402) 70- - 1770 updated certificate is received.
Renewal Registration #: If expired, please contact your insurance company and
have them send us current worker's compensation
certificate to:
,., ;,f ?_�e a €1 Nebraska Department of Labor
550 S. 16 Street
Contractor Registration Fee $40.00 Lincoln, NE 68509
Portal Fee $ 3.00 OR
Fax To: (402) 471 - 5039
Total Registration Fee $ 43.00
If you have any questions, please send them to:
OR
ftClis Gi? i7tl' �iCl. G? r(' i:_' 7 i t I' tillr ,?,i`td!l ?`'
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Ilavni.etnt € afr Call: (402) 471 - 2239
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Payment Voucher 4: 47754c691 b
Order In: 83401-92
Payment "I ; pe: AC[..I .
Account Nugmlber: 0170
Account Type: C1'ICt:kit�g �
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Name; 1 - Ic)Nl - DO (its ' 1 € \1C
Adds ess: 3.49 3 C.'C' kD 6
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https: / /do1.nebraska.gov /employers /regcontractors/ public /renewal /end. cfm ?tid =ne53 92084d... 6/6/2014
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OFFICIAL RESULTS REPORT t
764 - Nebraska (Bellevue) Roofing E
INIT RNATIGNAL Contractor /Subcontractor (E)
C00tiZ ONClL .
E
Name: DAVE WAKEHOUSE Candidate ID: ICNONO33350
Address: P O BOX 62 Date: 3/13/2014
TEKAMAH NE 68061
EXAMINATION RESULT: PASS
Congratulations! You have passed the above -named examination. You will be able to verify your pass
status on the ICC website within 48 -72 business hours after your exam. Please contact your
participating jurisdiction if you wish to pursue licensing.
A passing score on this examination satisfies the testing requirements for licensure only, and does not
guarantee that licensing will be granted. The candidate must also satisfy all local ordinance requirements
in each jurisdiction where licensing is desired.
It is extremely important that you notify Pearson VUE and ICC of any changes in name and /or address to
avoid the possibility of future correspondence not being received. Please contact both Pearson VUE at
877 - 234 -6082 and ICC at 888 - 422 -7233 ext. 5524 with changes to your name and address.
ICC reserves the right to amend or withhold any examination scores if, in its sole opinion, there is
adequate reason to question their validity.
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The authenticity of this score report can be validated by using Pearson VUE's Online score Report Authentication found at:
www.PearsonVUE.com /authenticate
Digital embossing eliminates the possibility of unauthorized embossing of counterfeit score reports.
Registration Number. • 265272984 Validation Number. • 262486714
I
CITY OF OMAHA, Nebraska
NO. 0 3493
THIS CERTIFICATE IS NOT TRANSFERABLE j
NAME LOCATION f
DAVE WAKEHOUSE DAVE WAKEHOUSE
WATERTIGHT ROOFING WATERTIGHT ROOFING
3493 COUNTY RD G 3493 COUNTY RD G
TEKAMAH NE 68061 TEKAMAH NE 68061
Class E Building Contractor $200.00
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EFFECTIVE DATE 31- JANUARY -2014
POST IN A CONSPICUOUS PLACE
EXPIRATION DATE 31- DECEMBER -2016
DIVISION Pe its Inspe
City of Omaha Planning Department BY
1819 Farnam Street Room 1100
Omaha, NE 68183
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Show Receipt Detail Page 1 of 1
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RECEIPT
City of Omaha Planning
PERMITS AND INSPECTIONS
1819 FARNAM SUITE 1110
Permits and Inspections
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Application: LIC -14 -00270 y
Application Type: Permits /LICENSES & EKAMS /BUILDING /CLASS E
Address:
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Receipt No 553567
Payment Method Ref Number Amount Paid Payment Date Received Comments
Check 1011 $200.00 01/31/2014
Work Description: Class E Contractor Lic
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