Select Registration 2014.tif FOR OFFICE USE ONLY
Date Paid:
218 S. 16t" Receipt No:
Street
Data Issued: �
Blai NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair @ci.btair.ne,us ❑
Application is: New Renewal
CONTRACTOR REGISTRATION/LICENSE RENE AL j
(Please type or print in ink — if you need more space, please attach additional sheets)
Application is for: Contracto - $60.0 ❑ 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
El Layer- - $ 60.00
Business Name: j
Applicant Name: W!
Business Add ress: . I NA S 7 C1ty: /7 State: i'5 — Zip .
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Email Address: /
Phone #:
. Fax Mobile
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Business Address outside of Nebraska:
City: State Zip: — Phone:
Contact Person:
Number of Employees: „ Apprentices: Journeymen:
Other Licenses Held:
insurance/Worker °s Compensation Company: _
Drain Layers /Electrical, Plumbing and Mechanical Contractors/Water Service Line installers need a $5,000 permit band 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. 1 will notify the City of Blair of any changes in the information
reported on or with this application form within IS 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. 1 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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Authorized Signature Date
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Department of Labor
4w,"� Labor Law / Contractor Registration
NEBR 550 South 16th Street, 3rd Floor
DEPAR TMENT OF LABO Lincoln, NE 68508
ww w,dol,iiet)raska.go (402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor /Subcontractor Name: SELECT SIDING & WINDOWS INC.
Address: 5030 SO 129th ST.
City: OMAHA
State: NE
Zip: 68137
Telephone: (402) 714 - 2252
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Certificate Number: 36604
Certificate Expiration: 03/15/2015
Contractor Option: 2
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