Performance Registration 2013.tif �C
FOR OFFICE USE ONLY
CITY OF BLAIR Date P 1d:
218 S. 16 Street Receipt No:
Date Issued:
Bl air, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: d ofblair@Ci,blainne.us
Application is: New ❑ Renewal
CON TRACTOR REGISTRATION/LICENSE RENEWAL
(Please type7 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
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Business Name:
Applicant Name:
Ci ty: State:
Business Address: -
Email Address: , r'
� " Mobile 5 #: e
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('hone #: � G � � ,�.._ , Fax #•
Business Address outside of Nebraska:
City: State Zip: Phone:
Contact Person. C
Number of Employees: P Apprentices: Journeymen:
Other Licenses Held:
° Company:
Insurance/Worker s Compensation
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 15 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 o y all order, re quirements and regulations of its lawful constituted authorities. This certification applies to the
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original livens registration and any renewals thereof.
Authori d Signatu x Date
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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. I
NO WORK SHOULD BE t .p -,
A GENERAL CONTS
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Three communities in which you are curren 47c),
( Community #1 : �� ,
7 Community #2 • �-- - �
Community #3: ,
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Three personal references for whom you h VM -.
Client #1
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Client #2 : °� Phone:
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Client #3 : > c - 1 6 Phone:
Contrac r /Applicant Date
References verified by: Date
218 South 161ti S,tree_l - Blair. Neabro -sags 68008 $ 402 -426 -4 191 m Fox 402 -426 -41195 E -mail cihjdbloit(�!C1. l0lr,ne.us '
B randy Petersen
From: Jason Clayton Dolavton .con]
Sent: Thursday 14 311 PW1
To: B randy
Sub RE: Please fill out and return
Attachments: BbairRafananue.odf
8nandy
To add to this form | can tell you that. | do come referred by Steve Nelson, President ofFarm Bureau in
Nebraska. | have managed a lot of claims in the past and am being referred to homeowners in Blair by them. | did come
in the night of the storm as a good Samaritan and helped people board up their homes ect.. Most who didn't even know
| was a roofing contractor because | don't operate like that. | was there to help when help was needed. | do not pester
homeowners by going up and down the streets door knocking. I work on referral basis only. I have already invested
advertising into the Blair community and on 97.3FM after | initially registered before this form became a requirement so
I already have a lot of funds invested. I already have appointments for tomorrow with some of Farm Bureaus
insured ... one of which has 5 rental properties to go over. I guarantee my customer service will be A+ to the residents of
the Blair community. I was born and raised in Omaha and am a graduate from Millard North in 1995. A lot of my recent
business is with commercial properties where the permits fall on the responsibility of the general contractor and
architects. Please keep me informed as this would be disastrous for my business if I am not approved for some reason. It
would have an impact on my relationships with insurance companies—especially Farm Bureau that I have work so hard
10 get in other areas.
Thank you very much Brandy
Sincerely,
Jason
Jason r �� -/��° Cla'
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Performance Roofing aRJ
I53IO J3C/CsDyl St788/
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Omaha, WE 601
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F-402'992-2173
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From: Brandy Petersen [ l
Sent: Thursday, June S,2O142:O3PW4
To:
Subject: Please fill out and return
Thank you!!!
Brandy Petersen
City of Blair
(P) 402-426-4191
(F) 402-426-4195