Legacy Registration 2016.tifCITY OF BLAIR
218 S 16TH STREET
BLAIR, NE 68008
(402) 426 - 4191
FAX (402) 426 - 4195
Email: cityofbiair@ci.blair.ne.us
FOR OFFICE USE ONLY
Date Paid: 1
Receipt No:!l I i o ke
Date Issued:
BOND EXPIRES•
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Legacy Homes Omaha, LLC
12040 McDermott Piz #200
LA VISTA, NE 68128
Phone numbers on record:
Type: Phone Number: Type:
Office 402 884 3202 Office
Mobile 402 536 0738
Email Address:
Please verify and correct
the company/business
information listed here:
Phone Number:
PLEASE SUBMIT A COPY OF YOUR
CURRENT it a i, J DEPARTMENT OF
LABOR. REGISTRATION
Type of Business: General YOUR CERTIFICATE OF LIABILITY
INSURANCE IS EXPIRED OR ABOUT TO
Please submit new certificates or bond renewals for those which have expired: EXPIRE. PLEASE SUBMIT A NEW COPY
Name Certificate of Liability or Bond Expires WITH YOUR RENEWAL.
Kafonek, Tom General Certificate of Liability 1/1/2016
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
Kafonek, Tom General Contractor 12/31/2015 $60
Please list any additional license or registrations:
Name License / Registration Amount
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 vocation. I gr to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocationand grey allprder, u' ements and regulations of its lawful constituted authorities.
�. ewe Z `
Auth rized Signature Date
NEBRASKA
DEPARTMENT OF LABOR
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Department of Labor
Labor Law / Contractor Registration
550 South 16th Street, 3rd Floor
Lincoln, NE 68508
(402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name:
Address:
City:
State:
Zip:
Telephone:
Certificate Number:
Certificate Expiration:
Contractor Option:
Legacy Homes Omaha, LLC
12040 McDermott Plaza, Suite 200
LaVista
NE
68128
(402) 884 - 3202
40675
07/01/2016
2