Loading...
HomeO Registration 2015.tif I S CITY OF BLAIR FOR OFFICE USE ONLY g Date Paid. 218 S. 16 Str Receipt No: Date Issued fa ir ® N E 68008 B OND EXPIRE (402) 426 4191 FAX: (4 2) 426 4195 i Em ail: dty ofbla ir@d.blair.ne.us Application is: R New E] Renewal CONTRACTOR REG t r r L I � (Please type or print in ink — if y u need more space, prase attach additional sheets) 1 Application is for: Contractor- $60.0 0 ❑ Electrical contractor- $60.00 Cj W ater Service Lin installer- $60.00 ❑Tree T rimmer- $60.00 D Fire /Security Syst rn installer- $25.00 ❑ Gras Line Installer- $2S.00 (J M Contracto $60.00 ❑ Plumbing Contractor- $60.00 f ❑ Drain Layer - $GB Business Name: o Applicant Name: �- Business Address- City: ��� State; z ip » 7 Email Address: .- P— sd�v'� 1 . phone #» ± 0 2— 0 l+ax Mobile #; i Business Address outside of Nebraska- 3 & 1 i3 7?.. zn- city.. State Zip: S:5 �-'- Phone: 40 2-- f 9' _ Contact Person. I Number of Employees. Apprentices: Journeymen: Other Licenses Held; Insurance/Worker's Compensation Comp ny: Drain Layers /Electrical, plumbing and Mechanical C ntractors/WaterService tine Installers need a $5,000 permit bond in favor of the City of Blair. 'Tree Trimmers need a $5,000 pe rmit bond In favor of the City of Blab Electrical Contractor and Fire f ,Security systems Installer will need to submit a cop 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, i hereby crake application to the Licensing Boarc of Blair, Nebraska and certify that I am competent and experienced to engage in above said vocation. I agree to confor n strictly to the Ordinances of the City of Blair, Nebraska relative to said vocation and obey all order, requirements and regL lations of its lawful constituted authorities. This certification applies to the original license and /or registration and any renewa s thereof. Authorized Signature Date i i i A CERTIFICATE LIA ILITY INSURANCE D 04/2 /201 YY) M 04/28/2015 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFC RMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIF CATE'OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESEN ATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. j IMPORTANT: If the certificate holder is an ADDITION L -INSURED, the policy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cert iin policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu Of such endorsement(s). PRODUCER CONTACT M & H INSURANCE AGENCY INC NAME: PHONE FAX 3020 WOODBURY DR ac No Ext: 'C, No: SAINT PAUL, MN. 55129 EMAIL ADDRESS: Phone: 651- 731 -8268 Fax: 651 - 731 - 4665 INSURERS AFFORDING COVERAGE NAICn 14184 INSURERA: ACUITY INSURED INSURER 8: MAGIS LLC INSURERC: 3013 13TH TER NW INSURER U: NEW BRIGHTON, MN. 55112 INSURER2 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PO ICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSD SWVD POLICY I UMBER (MM)DDffYYYY) (MM DDNYYY) LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ® OCCUR DAMAGE TO RENTED $ 100,000 PREMISES (Ea o D nce) X Bis -Pak Business Liability and Medical MED EXP (Any one person) $ 5,000 Exp enses CBX7 9901 09/18/2014 09/18/2015 - - PERSONAL &ADV INJURY Included EN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO PRODUCTS - COMP /OP AGG POLICY ® JECT ® LOC $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per p0mon) $ ALLOWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON -OWNED (Per PROPERTY $ F --- AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND PER OTHER EMPLOYERS' LIABILITY STATUTE _ ANY PROPRIETORIPARTNERI Y/N NIA E.L. EACH ACCIDENT $ EXECUTIVE OFFICER/ MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES CERTIFICATE HOLDER CANCELLATION City Of Blair SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ATTN: Contractor Registration ', DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 218 South 16th Street PROVISIONS. Blair, NE. 68008 AUTHORIZED REPRESENTATIVE '.. ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD nar ic and logo are registered marks of ACORD CL -517 (1 -14) r NCbrask�Depaitrnent of Lnbor ContrartorRe�nsvatton SQ.So. 16t1} Streek �inroln NE 68509 (t02) 471- 2239 Date Issued Date Expires i J 08/01/2013 08/0112014 CON CTORX2EGISTRAIIONCERUFICATE _ Thin uiifim 4e isnun tmnat��lu Fee Exempt 'Wgrstratton # 23,439 Business: HOME -ONE ROOFING OMA 0 II C [1, NE 8 T 37 cu um aiouerofL c ( . w I 1e �r P 11 -CR A i i I i I I Department of Labor Labor Law / Contractor Registration NEBRA.S KA 550 South 16th Street, 3rd Floor DEPARTMENT ENT Lincoln, NE 68508 p (402) 471 - 2239 Registered Contractors and Subcontractors Locator Contractor /Subcontractor Name: Home -One Roofing Address: 8945 J Street, Suite 7 17821 Bent Tree Ridge City: Omaha Council Bluffs State: NE IA Zip: 68127 51503 Telephone: (402) 213 - 9553 i Certificate Number: 23439 Certificate Expiration: 08/01/2015 Contractor'Option: 2 I I i I i I I I i I I I Department of Labor Labor Law / Contractor Registration 4WN�BRASK 550 South 16th Street, 3rd Floor DEPARTMENT OF LABOR Lincoln, NE 68508 : 4; ; ; ,? (402) 471 - 2239 I ! Registered Contractors and Subcontractors Locator Contractor /Subcontractor Name: Home -One Roofing Address: 8945 J Street, Suite 7 17821 Bent Tree Ridge City: Omaha Council Bluffs State: NE IA Zip: 68127 51503 Telephone: (402) 213 7 9553 Certificate Number: 23439 Certificate Expiration: 08/01/2015 I Contractor Option: 2 t i I i l I i i i i