Lockman Registration 2014.tif P.
FOR OFFICE USE ONLY
CITY OF BLAIR Date Paid: 41
218S.76 1h Street Receipt No
Date issued:
Blair, NE 68008 BOND EXPIRES'.,
(402) 426 4.191 FAX: (402) 426 4.195
Email: stormdamage@d.blair.ne.us Application is: N ew ❑ Renewal
CONT"CTOR REGISTRATION/LICENSE RENEWAL
(Please type or print in inic - if you need more space, please attach additional sheets}
Application is for: I Contractor- $60.00 ED Electrical contractor- $60.00
❑ water Service Line Installer - $60.00 7 Tree Trimmer - $60.00
❑ Fire/Security System installer - $25.00 ❑ Gas Line Installer -$25,00
❑ Mechanical Contractor- $60.00 El Plumbing Contractor $60.00
❑ Drain Layer - $60.00
Business Name: C-dif r 7 Z_
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Applicant Name: j6 _,re
State: Zip: Q
w. (0
Business Address. A
Email Address:
Phone #: 7U _7 Fax* Mobile* 70-
Business Address outside of Nebraska:
City: State Zip: Phone:
Contact Person:
Number of Employees: — , Apprentices: Journeymen:
Other Licenses Held: �z
Insurance/Worker's Compensation Company:
Drain La /Electrical, Plumbing and Mechanical Contractors/water Service Line Installers need a s5,000 permit bond in favor
o f t h e Cit of Bla [r, Tree Trimmers need a $5,000 permit bond in favor of the City of Blair. Efectrical Contractor and Fire
Security Systems installer will need to submit a cop of y our Nebraska State License.
General Contractors need to submit a Certificate of Insurance with minimum l o f $ 1,000,00OAggregate/$300,000 each
occurrence.
All information contained in this application is true and correct. I will notify the cit of Blair of any changes in the information
reported on or with this application form within I S da of the chan
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and experienced to
en in above said vocation. I a to conform strictly to the Ordinances of the City of Blair, Nebraska reJative to said
vocation and obey all order, re and re of its iawful constituted authorities. This certification a pplies to the
ori Ircense and /or re and an renewals thereof.
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Authorized ture Date
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CITY 1.jA1Q-
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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 WORD SHOULD BE DONE PRIOR TO RECEIVING
A GENERAL CONTRACTOR REGISTRATION.
Three ccmmunities in which you are currently registered and have been issued permits:
Community #1 : Phone: `� ��' ' 4yl- 535
Community #2 : Phone: -
Community #3: Phone:
Three personal references for whom you have recently done worm:
r
Client #1 : �� �� , t Phone: li 6 30 - f ?
Client #2 : c- ki4i N- 4%er Phone: � - c1 -i -- g 7.6 - d
Client #3: Mcukjcj CK Lin,sj, Phone: 3 3 �- dfdo
L uc C lit Yn a.4 En
Contractor /Applicant �— Date
References verified by. Date
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218 St Wh 16th Sireet • Blair, Nebraska 68008 • 40 426 -41191 4 fax 402- 426 -4195 E -mall cltyolbiair cl.btalr.ne,us 11'JOWYV I,ST