Prime Registration 2014.tif I
FOR OFFICE USE ONLY
Date Paid:
21 th Street Receipt No
Date Issued:
B lair, N 6800$ BOND EXPIRES:
(402) 426 4191 : (402) 426 419
E mail: cityofblair @ci.blair.ne.us
Application is: ❑ New ❑ Renewal
CON TRACTOR I I /I L
(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
Business Name: ► '`� ��� ` �- i C" L -
Applicant Name: / I c
Business Address: — iL L , fso 1 City: N - i State: ( - Zip:
Email Address: / C 4 lC f g, 6- C()X,r Q-'7`
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Phone #: I6y? Fax #: Mobile #
Business Address outside of Nebraska:
City: State Zip: Phone:
Contact Person:
Number of Employees: Apprentices: Journeymen:
Other Licenses Held:
Insurance/Worker 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
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 I am competent and experienced to
engage in above said vocation. 1 agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation a� d bey all order requirements and regulations of its lawful constituted authorities. This certification applies to the
original I'fen and /or re ' tration and any renewals thereof.
3.
Auth 6d Si nature Date
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CITY BLAIR FOR OFFICE � USE ONLY
Date Paid:
th ` �W
218 . 1 G Street Receipt No:
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 : (402) 426 4195
Email: cityofblair@ci.lair.ne.us
CONTRACTOR i
REG ISTRATION/ L I CENSE
(Please type or print in ink — If you need more space, please attach additional sheets)
i
Application is for: Journeymen /Apprentice - $25.00 each
Business Name: r�Yl�2 c���' L7' r�/ C_
Master's Name: C, A-
Business Address: (/PI city: State: '&� Zip: � e a
Phone #: �` ®G C S 2 Mobile #:
Please List all employees that you wish to register and check the appropriate boxes.
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Name Plumber Heater Electrician Apprentice Journeyman
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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.
t orized Signature Date
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Nebraska Department of Labor
y� Labor Law / Contractor Registration
550 So. 16 Street
Lincoln, NE 68508
ww) ol.nebraska.gov (402) 471 - 2239
Thank you for renewing your Contractor Registration with the Nebraska Department of Labor.
Print This Page
Please print this page as your reciept.
i
Contractor Information If you have any questions, please send them to:
Prime Electrical Services LLC ndol contractorrecistr ation a nebraska.gov
2035 N 81 st Street OR
Omaha, NE 68134 Call: (402) 471- 2239
(402) 393 - 0320
(402) 960 - 1657 j
Renewal Registration #: 39488
Contractor Information
Contractor Registration Fee $40.00
Portal Fee $ 3.00
Total Registration Fee $ 43.00
- Payment Information -
Payment Voucher #: 2e434a725d
Order ID: lb" 8685350
Payment Type: CC C
Account Number: 6234
Account Type: Visa Card
Name: Rick Kyle
Address: 2035 N 81st St
City: Omaha
State: NE
Zip: 68134
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Country: us
Phone: 402- 960 -1657
Email:
rickakyle a cox.net
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