Jorgensen Registration 2015.tif i
r
CITY OF BLAIR I
FOR OFFICE USE ONLY
218 S 16TH STREET
� BLAIR, NE 68008 Date Paid:
Receipt t No: l
ry (402) 426 - 4191 P —
Date Issued:
FAX (402) 426 - 4195 ND EXPIRES
f a; -is Email: cityofbiair @ci.blair.ne.us B � _
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please veri and correct
the company /business
Jorgensen Contracting, Inc. information listed here:
530 Front St
Blair, NE 68008
Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Office 402 426 4440
Mobile 402 533 3165
Email Address:
Type of Business: GENERAL
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Jorgensen, Gerald P. General Certificate of Liability 1/31/2015
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
' Jorgensen, Gerald P. General Contractor 12/31/2014 $60
Please list any additional license or registrations:
Name License / Registration Amount
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PLEASE SUBMIT A CO- f OF i �jR
CURRENT E I d_' � 4tA E T OF
LABOR RE I ®0 ®AT41
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
vocation d obe all order, requirements and regulations of its lawful constituted authorities.
0 6--'o
Author"ed ure Date
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Page I of 2
Nebraska Department of Labor
Labor Law / Contractor Re
550 So, 161h Street
Lincoln NE 68508
Wjj,7
w.dol.ncbras ka.gov (402) 471 - 2239
Thank y ou for renewin y our Contractor Registration with the Nebraska Department of Labor.
I Print This Pa
Please print this pa as y our retie t.
Conti-actor Information NOTICE: The worker's comp. certificate we have on
JORGENSEN CONTRACTING, INC. file expires on: 01/01/2015. Any contractor whose
530 FRONT ST records indicate their covera has expired, will be
BLAIR, NE 68008 removed from the list of re contractors until an
(402)426-4440 updated certificate is received.
(402) 533-3165
Renewal Re #: 23004 If expired, please contact y our insurance compan and
have them send us current workers compensation
certificate to:
Conti-actor Information Nebraska Department of Labor
550 S. 16'hStreet
Contractor Re Fee $40.00 Lincoln, NE 68509
Portal Fee $3.00 OR
Fax To: (402) 471 - 5039
Total Re Fee $43.00
If y ou have an q uestions, please send them to:
-idol. contractorm-yi stradon(a .,6Ira,,k1ra.-.ov
OR
Payment Information - Call: (402) 471 - 2239
Pa Voucher #: 2le31b2f42
Order 11D: 10765229
Pa T y pe: cc
Account Number: 0437
Account T Visa Card
Name: Jor Contracting
Address: 530 Front St
Cit Blair
State: NE
Zip: 69009
Countr US
Phone: 402-426-4440
Email:
j6@11111-1tel.net
https://dol.nebraska.gov/employers/regcontractors/public/renewal/end.cfm?tid=ne548ca3... 12/13/2014