20121010083812358_0001.tif FOR OFFICE USE ONLY
Date Paid:
Receipt No.
218 S. 16 Street Date Issued:
Bla NE 68008 BOND EXPIRES:
(402) 426 4191 FAX: (402] 426 4195
Email: djy f fir @ci blair.ne.us
Application is: ❑ New ❑ Renewal
C REGI RENEWAL
(Please type or print in ink — if you need more space, please attach additional sheets)
Application is for: D Contractor -
❑ Electrical Contractor - $60.00
❑ Water Service Line Installer - $60.00 ❑ Tree Trimmer- $60.00
system Installer- $25.00
❑ Fire /Security Sys ❑ Gas Line Installer- $25.00
❑ Mechanical Contractor- $60.00 El Plumbing Contractor- $60.00
❑ Drain Layer- $60.00
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Business Name:
Applicant Name:
r� 2�J/ City: '� State:
Business Address: , �` � `-�
Phone #: T��� %� Fax #: Mobile #:
Business Address outside of Nebraska:
City:
State Zip: Phone: j
Contact Person
Number of Employees: Apprentices: Journeymen:
Other Licenses Held:
insurance /Vtorker'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 /$300,00 each
occurrence.
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.
1 hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 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 s
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.
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Date
Authorized Signatu
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