Sterling Registration 2015.tif i
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FOR OFFICE USE ONLY
CITY OW D"LA110 �Q
Date Paid:
218 S. 16 Street Receipt No LJ
Date Issued:
Blair, NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402) 426 4195
Email: cityofblair @ci.btair.ne.us
Application is: New ❑ Renewal
CONTRACTOR REGISTRATION/LICENSE RE E AL
(Please type or print in ink —1f 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:
Applicant Name: C — LIrl 11 A C, ✓l ^-s
Business Address: 2 71.E I _ � City: /� �' State: Zip: Ew e
Email Address: �C�C�tc�.A J - ems° 1 ✓�� 1'� v; �,
c ° � Mobile #. Z' D- 7/ I f
Phone #: � � - �'.� °�� Fax #: , �n�° _ ,�,- �
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 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. 1 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 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 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.
Aut orized Signature Date
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CITY OF BLAIR
CONTRACTOR REGIST N ACT
E XEMPTION CERTIFICATI
Date:
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According to the exemptions authorized in the Contractor Registration Act (Nebraska Statute §48-
2101 to 48- 2117), I hereby certify that the Contractor indicated below is exempt from registering as
a contractor under the Contractor Registration Act for the following reason(s):
The contractor:
1. Is not engaged in the business of the construction, alteration, repairing, dismantling, or
demolition of buildings, roads, bridges, viaducts, sewers, water and gas mains, streets,
disposal plants, water filters, tanks and towers, airports, dams, levees and canals, water
wells, pipelines, transmission and power lines, and every other type of structure, project,
development, or improvement within the definition of real property and personal
property, including such construction repairing or alteration of property to be held
either for sale or rental
2. Only performs construction work on property which is owned, leased or rented for their
use.
❑ The contractor earns less than $5,000 annually for construction services.
Contractor Name: s v
Mailing Address: Ido f , - r �QE
Applicant Signature:
Applicant Name (printed): �� �n � LL P,
Title: V P 0'0