Monarch Registration 2015.tif I
Apr 08 15 08,23a Monarch 4028981131 p.2
sw I
FOR OFFICE USE ONLY
-
-
DawPaid: r. di LIVO
218 S. 16M Street BeceiIstue
Date Issued:
@lair, NE 68008 SONDWIRES:
(402) 426 4191 F Ak (402) 426 4195
Email: cityofblair @ci.blair.ne -us
Application is: `New ❑ Renewal
CO NTRACTOR REG ISTRATION/LICENSE RENE L
{Please type or print in info — If you need more space, please attach additional sheets)
Application is for: L 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 - $2S.00
❑ Mechanical Contractor - $60.00 ❑ Plumbing Contractor- $ 60.00 j
[} Drain Layer - $60.00
Business Name. '
Applicant Name. 1 j
Business Address. r City: if l State: _Zip: - &�
Email Address
Prone #: � J �O " F x #Z Mobile #:
Bussiness Address outside of Nebraska: l
City: State Zip: Phone:
a
Contact Person:
Number of Employees; -Apprentices: Journeymen:
Other Licenses Held: L I , .
Insurance/Worker's Compensation Company: B� /t°rS
Drain Layers /Electrical, Plumbing and Mechanical Contra Line Installers need a $5,000 permitbond In favor
of the City of Blair. Tree Trimmers need a $5,000 permit Bond In favor ofthe City of Blair. Electrical Contractorand 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 $'I ,000,000 Aggregate /$300,000 each
®tturrence.
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 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.
P
3
I
uthorized Signature Date
i
f
F
aR 0815 0e23a Monarch 4028981131 ms
�
�
�
/
\ \ I
@ \
/ = E
J tri k �
< o
\ i
\ § .
-
/
/ c \
\
. 2
% }) i
g F\
\ �
\
\ \
g \ .
\ / �
\ \
/ rD 2
\ ! £ -
�e �
ON \
§ \
d c