Takoda Registration 2014.tif 4
I
FOR OFFICE USE ONLY
0 F BIMA I R Date Paid:
Receipt No.
218S.16 t " Street Date Issued:
Blair, NE 68008 BOND EXPIRES: k
(402) 426 4191 FAX: (402) 426 4195
Em stormdamage9d.blainne.us Application is: ❑ New ❑ Renew
OR REGISTRATION/LICENSE CONTRACT RENEWAL p lease attach additional sheets)
(Please type or print in inic — if you need mores ace, p
dContractor - $60.00 El Electrical Contractor - $60.00
A lication is for: _ Tree Trimmer $60.00
PP ❑ Water Service Line Installer $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
C - qre P- T
Business Name:
nt Name•
Applicant
City: State• Zip:
Business Address:
Email Address: cksc co
' Fax #:
Mobile
Phone #: X d - �� � �
Business Address outside of Nebraska:
City:
State Zip: Phone:
Contact Pers
r Apprentices: Journeymen:
Number of Employ ees: _
Other Licenses Held:
Insurance/Woricer's Compensation Company:
plumbing
and Mechanical Contractors/Water Service Line Installe r En ed �ic 1 Cont perm b nd in favor
Drain Layers /Electrical, Pl 9
of the City of Blair. Tree Trimmers need a $5,000 permit Nebraska State Li cense.
Bia 000 each
General Contractors need to submit a Cert
Security Systems Installer will need to submit a copy y
ificate of Insurance with minimum limits of $1,000,000 Aggregate/ 300,
occurrence.
'n this a is true and correct. 1 will notify the City of Blair of any changes in the information
All information contained pP
reported on or with this application form within 15 days of the change. t o
1 hereby make application to the Licensing
Board of Blair, Nebraska and certify that i am competentr�s a relative to said
engag e in above said vocation. 1 agree to conform strictly to the Ord c onstituted u aut orit es. Bl air, his a tification applies to the
vocation and obey all order, requirements and regulations of its la
original license and /or registration and any renewals thereof.
f
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CITY Of BLAIQ
r
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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
cu rrent.
NO WORK SHOULD BE DONE PRIOR TO RECEIVING
A GENERAL CONTRACTOR REGISTRATION.
Three communities in which you are curr egistered and have been issued permits:
Phone:
Community #1
Community #2: _ , r� }-�.� Phone:
#3 : Phone: f? '
C �.�.�._.
Three personal references for whom you have recently done work:
Client #'! : Phone: V . Z.
Client #2: Phone:
Client #3 : l d. Phone:
o ract pp ant DA
References verified by: Date