TotalRo Registration 2015.tif i
CITY OF BLAIR FOR OFFICE USE ONLY
218 S 16TH STREET
BLAIR, NE 68008 Date Paid:
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(402) 42.6 - 4191 Receipt No:
FAX (402) 426 - 4195 Date Issued:
Email: cityofblair @ci.blair.ne.us BOND EXPIRES
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
the company /business
Total Roofing Company information listed here:
10501 Chandler Cir
LAVISTA, NE 68128
Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Office 402 334 2755
Fax 402 334 3413
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
Magsam, Mitzi General Certificate of Liability 6/16/2015
Place a check in the box next to the licenses you wish to renew:
Renew; Name License / Registration Expires Amount
Magsam, Mitzi General Contractor 12/31/2014 $60
Please list any additional license or registrations:
Name License / Registration Amount
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PLEASE SUBMIT A COPY OF YOUR
CURRENT NEBRASKA DEPARTMENT" OF
LABOR REGISTRATION
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 v ation. I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation and o order, requirements and regulations of its lawful constituted authorities.
Authorized Signature Date
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Department of Labor
Labor Law / Contractor Registration
4ffN%RASKA 550 South 16th Street, 3rd Floor
Y E)"EPARTMENT OF LABOR Lincoln, NE 68508
(402) 471 - 2239
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Registered Contractors and Subcontractors Locator
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Contractor /Subcontractor Name: TOTAL ROOFING INC.
Address: 10501 Chandler Circle, Suite 100
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City: OMAHA
State: NE
Zip: 68128
Telephone: (402) 334 - 3406
Certificate Number: 24143
Certificate Expiration: 01/15/2016
Contractor Option: 2
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