ArkC Registration 2014.tif FOR OFFiCE USE ONLY
CITY OF BLAIR
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218S.16 th Street Receipt No:
Date Issued:
Blair, NE 68008 BOND MPIRES:
(402) 426 4191 FAX (40 2) 426 4195
Email: Cityofblair@ci blair.ne.uS ❑
Application is: New Renewal j
CONTRACTOR R EGISTRATION/LI C ENS E
(Please type or print in ink— If you need more space, please attach additional sheets)
Application is for: W 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 - $2S.00
❑ Mechanical Contractor- $60.00 ❑ Plumbing Contractor- $60.00
❑ Drain Layer - $60.00
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Business Name:
Applicant Name:
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Business Address. �� � �..� ty : State: Zip:
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Email Address. `o
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Phone #: m � Fax #: Mobile #:
Business Address outside of Nebraska
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- 71
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Cit : State Zip. Phone.
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Contact Person: °°°`�� �"� ,
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Number of Employees: 0. Apprentices: Journeymen:
Other Licenses Held:
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Insurance/Worker's 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 I
reported on or with this application form within 1 S 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.
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Aut ; orized Signature J Date
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Nebraska Department of Labor
Contractor Registration
550 So. 16th Street, Lincoln NE 68508
u, (402) 471 -2239
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Date Issued Date Expires
07/01/2014 07/01/2015
CONTRACTOR REGISTRATION CERTIFICATE
fi This certificate is non- transferable
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Fee Paid: $40.00 Registration #
43867
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Year
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Business:
f ARK CONSTRUCTION
�' 411 E MARTIN ST. Comrnissioneroft4r
MODALE, IA 51556
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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 inforrhation is required.
References will be checked so please ensure. reference names and phone numbers are
current.
NO WORK SHOULD BE DONE PRIOR T O RECEIVING
A GENERAL CONTRACTOR REGISTRATION.
Three communities in which you are currently registered and have been issued permits:'
Community #1 : Phone:
Community #2: Phone.
Community #3: Phone:
Three personal references for whom you have recently done work:
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Client #1 : Phone: -1 �0
Client #2: �� �.j Phone:
Client #3: " �� �` � ` ' Phone: 0(
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Contractor /Applicant Date
References verified by: Date
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218 Sou 16th St. e • Rica, i0sk&68Q08 + 4Q2,-4-26- Pao( 402 - :1 E M-164 ci vftlOko- 01 btairnaus