Matthew Registration 2014.tif FOR OFFICE USE ONLY
Date Paid
Receipt No:.
218 S. 16 Street Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: stormdamage @6blainne.us Application is ❑ New ❑ Renewal
CONTRACTOR REGISTRATION /LICENSE RENEWAL
(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 J
BusinessName: Mcdd e'�'-
Applicant Name: LIIr � )�`"`
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Business Address:
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Email Address:
Phone #: Vl� 2 —.r V Fax #: Mobile #: o l
Business Address outside of Nebraska:
City: State ZIP
Phone:
Contact Person:
Number of Employees: Apprentices: Journeymen:
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4V 65V
Other Licenses Held:
Ins urance/Worker'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 Aggregate /$300,00 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 authorities. This certification applies to the
original license and /or registration and any renewals thereof.
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Date
uthorized Signature
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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 WORK SHOULD BE DONE PRIOR TO RECEIVING
A GENERAL CONTRACTOR REGISTRATION.
Three communities in which you are currently registered and have been issued permits:
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Community #1 :l yµ Phone: �e 3-� y `� �
Community #2: c "' Phone: 1 J
Community #3: Phone:
Three personal references for whom you have recently done work:
Client #1 ) C Phone:
Client #2 : T Phone:
Client #3: R t, �.. c Phone: � `° 4�
actor /Applicant Date
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References verified by: Date
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218 South 15th Street ° Blain Nebraska 68008 • 402-426 -4141 Fox 402 -425 -4195 E -mail cltyofbialr @cl,blair.ne.us