Madsky Registration 2014.tif i
r
CITY OF BLAIR
FOR OFFICE USE O ONLY
Date Paid:
218S.16 th Street Receipt No
Date issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityoffilair@d.bl
Application is; New ❑ Renewal
f
CONTRACTO REGISTRATION/LICENSE RENEWAL f
(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
Business Name: Gt k. 'n L L
Applicant Name: C
Business Address; City: - I State: Zip:
,fi r 03
Email Address: . i C e s) n CAS
Phone #: - - - 9 1 Fax #: � S5 - 5 dq -L400 9 Mobile #:
Business Address outside of Nebraska: 1 10, 3 0 l d
City: f State C I D Zip: & Phone:
Contact Gerson: rl s �-
Number of (Employees: l Apprentices: Journeymen:
Other Licenses Meld: �il ' �°
Insurance/Worker's Compe Com pan y :
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
i
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.
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 /or registration and any renewals thereof.
AgZ
t
Authorized Signature Date
i
I
i
3 i 1
i
7 .
{
---" 0 I)tAIQ
f
4
GENERAL CONTRACTOR REGISTRATION REFERENCES
i
i
t
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 check, so please ensure that reference names and phone numbers are
current.
i
NO WORK SHOULD BE DONE PRIOR TO RECEIVING �
A GENERAL CONTRACTOR REGISTRATION.
Three communities in which you are current registered and have been issued permits: r
Community #1 ; �
: - . � � A Phone: 1 41
Communit Phone:
f "r't .. e
Phon Community #3 t ��� � � � x��v . � �°
Three personal references for whom you have recently done work:
-
i
Client #'l : Phone:
Client #2 ,
�� --- £ zt. �, w� Phone:
i
Client # 3 : Phone:
AV
Aa?
I
i
Contractor /Applicant Date
i
I
References verified by: Date
i
i
i
i
IWIIIn t
i
218 South 16th Street * Blair, Nebraska 68008 • 402- 426.4191 • Fax 402.426.4195 E -mail cityofblalr @cl,blalr.ne,us
s
i
i
Department of Labor
Labor Law / Contractor Registration
4E NEBRASKA 550 South 16th Street, 3rd Floor
DEP ARTME NT LABOR Lincoln, NE 68508
il t (402) 471 - 2239
U_- x�
Registered Contractors and Subcontractors Locator
Contractor /Subcontractor Name MADSKY Roofing & Restoration, LLC
Address 233 South 13th Street Suite 1900
City Lincoln
State: NE
Zip: 68508
i
Telephone (855) 623 - 7597
Certificate Number: 42617
Certificate Expiration 01/01/2015
Contractor Option: 3
I
I
r