Luxa Registration 2016.tifCITY OF BLAIR
218 S 16TH STREET
BLAIR, NE 68008
(402) 426 - 4191
FAX (402) 426 - 4195
Email: cityofblair@ci.blair.ne.us
FOR OFFICE USE ONLY
Date Paid: "
Receipt No: iF i
Date Issued:
BOND EXPIRES'
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Luxa Construction Company, Inc.
925 E Dixon Rd
Blair, NE 68008
Phone numbers on record:
Tvpe: Phone Number: Type:
Office
Mobile
Email Address:
402-426-2778
402 510 8200
Please verify and correct
the company/business
information listed here:
.4 N
Phone Number:
PLEASE SUBMIT A COPY OF YOUR
LABOR REGISTRATION
Type of Business: GENERAL
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond
Expires
Luxa, Mike General Certificate of Liability
8/1/2016
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration
Expires Amount
Z Luxa, Mike 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 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.
Authorized Signature Date
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name:
Address:
City:
State:
Zip:
Telephone:
Certificate Number:
Certificate Expiration:
Contractor Option:
LUXA CONSTRUCTION COMPANY,
INCORPORATED
PO BOX 105
BLAIR
NE
68008
(402) 426 - 2778
22236
10/01/2016
2