MidlandU Registration 2014.tif CITY OF B LAIR F OFFICE US
218 S 16TH STREET
f4 ( BLAIR, NE 68008 Date Paid: b` 60D 402) 426 - 4191 Receipt No:
❑ * w 1 FAX (402) 426 - 4195 Date Issued:
d ". o BOND EXPIRES
o� Email: cityofblairci.blalr.ne.us - - - - --
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
the company /business
Midland Trenching information listed here:
5240 Co Rd 40
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Ft. Calhoun, NE 68023
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Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Office 402 573 5018
Mobile 402 6812015 Please submit a copy of your
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Email Address: current City of Omaha License
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Type of Business: Drainlayer
Please submit new reciprocating license for those which have expired:
Name Reciprocating License Expires
Kimberling, Steve Omaha Plumber License 12/31/2013
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Kimberling, Steve Drainlayer Bond 4/20/2014
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
❑ Kimberling, Steve Drainlayer 12/31/2013 $60
Please list any additional license or registrations:
Name License / Registration Amount
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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 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
voc tion and obey all rder requirements and regulations of its lawful constituted authorities.
Authorized Signature Date