TotalRo Registration 2014.tif FOR OFFICE USE ONLY
CITY OF BLAIR Date Paid
218 S. 16'h Street Receipt No:
Date Issued-
Blair,, NE 68008 BOND EXPIRES:
(4 2) 426 4191 FAX: (402) 426 4195
Email: dtvofblair@ci.bla1r.ne.us
Application is. New Renewal
CONTRACTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in ink - If you need more space, please attach additional sheets)
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
❑ Mechanical Contractor- $60.00 ❑ Plumbing Contractor- $60.00
❑ Drain Layer - $60.00 - 4 1
Business Name:
Applicant Nam e pk(y
� C"' state: zip:
Business Address: ci ty:
Email Address:
!'hone #: Fax #: 13 Mobile #:
Business Address outside of Nebraska:, 0
City: State Zip: Phone:
Contact Person:
Number of Employees: _Apprentices: Journeymen:
Other Licenses Held: 0
Insurance/Wori(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/$300,000 each
occurrence.
All information contained in this application is true and correct. I will notify the city of Blair of any changes in the Information
reported on or with this application form within 1 5 days of the change.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and experienced to
engage in above said vocation, I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation and obey all order, requirements and regulations of its lawful constituted authorities. This certification applies to the
original license and/or registration and any renewals thereof.
Authorized Signature w Dare
Jun, 18, 2014 3 07P CITY OF BLAIR (402. 426. 4191) No, 3857 P. 2
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GENERAL CONTRACTOR REGISTRATION REFERENCES
Due to the large number of general contractors seeking roofing and siding work within the
zoning jurisdiction of the City of Blair, the following reference information is required.
References will be checked, so please ensure reference names and phone numbers are
current.
NO WORK SHOULD BE DONE PR IOR TO (RE CEIVING
A GENERAL CONTRACTOR REGISTRATION.
Three communities in which you are currently registered and have been issued per i .
Community #1 : Phone:
Community #2: Phone:
Community #3: Phone:
Three personal references for whore you have recently done work:
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Client #1 . g' Phone:
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Client #2 . P �.
Client
# r=, , Phone. . _
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Contractor /,�kpplicaht, Date
References verified by; Date
216 SQ uth 1 4th S`lrtb-Ot Btafr, Nebraska 66QQ$ e 40.2- 426.4191 4 .rox 402 - 426.4195 1~rYialt dty0fb1a1r(5d.b10(rn0lus
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Nebraska Department of Labor
Contractor Registration
j 550 So. 16th Street, Lincoln, NE 68508 2
(402) 471 - 2239'
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Date Issued P
Date Expires j
01/15/2014 01/15/2015
CONTRACTOR REGISTRATION CERTIFICATE 1
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Fee Paid: $40.00 Registration 1;:
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Year
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Business: s
BRADCO INC,
10501 CHANDLER CIRCLE, SUITE 100 Commissionmr01 )r ; ,x
LAVISTA, NE 68128
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Nebraska Departlueot of Labor
Contractor Registration
550 So. 16th Street „ Lincoln, NE 68508
(402)'471 -2239 1
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Date Issued Date Expires
01/15 /2014 01/15/2015
CONTRACTOR REGISTRATION CERTIFICATE
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Fee raid: $40.00 Registration #
24143
Year 1
14 1
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Business:`
TOTAL ROOFING INC.
10501 CHANDLER CIRCLE, SUITE- 100 CommissioncrorL
OMAHA, NE 68128
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