Roy Registration 2014.tif i
CITY OF BLAIR FOR OFFICE USE ONLY
Date Paid: q A s� j
218 S. 161" Receipt No Street r
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair @ci.blair.ne.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 � Contaac r $60.00, ❑ Electrical Contractor -$60.00
F 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 - $6C,00
Business Name:
Applicant Name:
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Business Address: City: Oda r 6 State zipA I '
Email Address: I c duo r 6 LD I�
Phone # .Laa- 11 _51 r Fax #: ( A)9 fl Mobile #:
Business Address outside of Nebraska: Y-0 G 6 w h I� V - e W hI e 3"j, C k� rv►n1
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City: State Zip: Phone:
Contact Person: u o cVr 5
Number of Employees: C Apprentices: Journeymen:
Other Licenses Held:
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Insurance/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 /$300,000 each
occurrence.
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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,
1 hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 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.
- 2&�
Authori d Signatur Date
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l� Nebraska Department of Labor
n j r Labor Law / Contractor Registration
550 So. 16 Street
www,dol.nebraska.gov Lincoln, NE 68508
(402) 471 - 2239
Thank you for registering for Contractor Registration with the Nebraska Department of Labor.
Print This Page
Please print this page as your reciept.
Contractor Information If you have any questions, please send them to:
Roy Rogers Remodeling, Inc taclgl . MhK s�
11728 w Dodge Rd OR
Omaha, NE 68154 Call: (402) 471 - 2239
(402) 991 - 5151
(612) 498 - 0451
Conti-actor Information
Contractor Registration Fee $40.00
Portal Fee $ 3.00
Total Registration Fee $ 43.00
Payment Information -
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Payment Voucher #: le5d66f '216
Order ID: 9116816
P ayment Type: CC
Account Number: 8533
Aciount'1'ype: Visa Card
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Name: Roy Rogers
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Address- 457 Overlook Pass
City: Hudson
State: wl
Zip: 54016
Country- L ;S
E Phone: 612- 598 -0451
Exu a €l:
hailciamac„4pro 3@gmail corn
https : / /dol.nebraska.gov/ employers /regeontractors/ public /newreg/end.cfin ?tid =ne53 dfbd2f8... 8/4/2014
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