D&M Registration 2014.tif CITY OF BLAIR FOR OFFICE USE
Date Paid i i ['". ( �
218 S. 16 St reet BecelptNo t.
Date issued.
Blair, NE 68008 BOND EXPIRES'.
(402) 426 4191 FAX. (402) 426 4195
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Email: cityofbiair @ci.blair.ne.us
Application is: New ❑ Renewal �
CONTRA REGISTRATION /LICENSE RENEWAL
(Please type or print in ink -- if you need more space, please attach additional sheets)
Application is for Contractor- $60.00 ❑ Electr 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
Bus iness Name:
Applicant Name: O.P. e evi 4
Business Address. i 1 o; `i TI a,, L - a s r City: _6a_ State; KC _ Zip:_gt
Email Address; Cta+rti{I�nYar *���L Cc ti �a `cA��
Phone #: Fax #: < In - -44 Mobile 4k qQ# ,-
Business Address outside of Nebraska:
City: State Zip: _ Phone:
Contact Person:
Number of Employees; r_. Apprentices: Journeymen:
Other Licenses Held:
insurance/Worker's Compensation Company:
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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 ofyour Nebraska State License. f
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.
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 ;authoritles. This certification applies to the
original license and /\, registration and any renewals thereof.
Authorized Signature Date 1
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4WN Department of Labor
Labor Law / Contractor Registration
Li 1? 550 South 16th Street; 3rd Floor
DEPARTMENT UE LABOR. Lincoln, NE 68508
(402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor /Subcontractor Namc: DndM Rooting Inc
Address: 17559 Taylor Street
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City: Omaha
State: NE
Tip: 68116
Telephone: (402) 289 - 4776
Certificate Number: 41432
Certificate Expiration: 06/01/2015
Contractor Option: 2
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