Legacy Registration 2015.tif G L'
FOR OFFICE USE ONLY
Gate raid:
Receipt No:
218 S. 16 th Street ante rssued:_ �--
Blair, NE 6800$ satJal= xrrecs:
(402) 426 4191 FAX: (402) 426 4195
Email: s' orMdal aqe @cl.bl.air.ne.us A is: � New ❑ renewal
CONTRACTOR REGIS TIONAICENSE RENEWAL
(['lease type or pr i n t in Init- If.ypu need more space, please attach additional sheets}
Application is for.:.. C contracto - .00
❑ Electrical Contractor- $60.0
n Water service Line Installer- $60.00 ❑ Tree Trimmer- $60.00
Fire /security system installer- 525.00 ❑ Gas Line installer - $25.00
❑ El Contractor - 560. Plumbin
❑ Mechanical Contractor- $60,00 g
❑
Drain Layer- $60.00
Business Name:
Applicant Name: t = ��0-\ + k
Business Address:
2DL4 0 � \c1�e?t -'H Pty . -2 City: -ceyrs� State :I di [�P�t2
-1° CJ E^+(�, �G C.(. � - t7I`� � �. � 1-H -G -� G.�f � Et �n �' ^^� C7 f.�`lE -Gl-- X11[.$ • C. f�
Email Address: {
Phone #' �(� �- ����.j _ a 2Uz- Fax Irk 1
mobile nr.. �(�'L - c_�'�lt� U 3 5
Business Address outside of Nebraska:
City:
State Zip: �- Phone:
i
Contact Person:
35, —Apprentices: Journeymen:
Number of Employees: Pp
other Licenses Held:
C...�GL
Insurance/Woricer's Compensation Compa C)4 S
Drain Layers/Electrical, Plumbing and Mechanical Contractors /vlaterservice Line Installers need a Ss,000 permit bond in favor
of the city of Blair. Tree Trimmers need a $5,{}00 permit bond In favor of the City of Blair. Electrical Contractor rend Fire
securitysystems instailerwill need to submit a copy of your Nebrasisa state License. re ate $30{1,000 each
General Contractors need to submit a Certificate of Insurance with minimum rimits of $1 jim,000 Agg
occurrence.
All information contained in this application is true and correct. I will notify the City of glair of any changes in the information
reported on or with this application form within 15 clays of the change.
I hereby make application to th e Licensing Board of r3lalr Nehrasrca and certify that I ain Blam ebraska relative to tiv o s id
engag in above said vocation. I agree to corif OY ll strictly to the ordinances Of tile City of
vocation and obey all order, requirements and regulations of its lawful constituted authorities. This certification Applies to the
original license and /or registration a a renewals thereof.
>Aclthorized Signature ate k
�-
I
Department of Labor
Labor Law / Contractor Registration
4 WN E B R A S K A 550 South l6th Street. 3rd Floor
DEPARTMENT CAP LABOR Lincoln, NE 68503
(402) 471 - 2 239
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name: Legacy Homes Omaha, LLC
Address: 12040 McDermott Plaza, Suite 200
Cite: LaVista
State: NE
Zip: 63123
Telephone: (402) 881- 3202
Certificate Nuntber: 40675
Certificate Expiration: 07/01/2015
Contractor Option: 2
I
i
I
i
i