Application for Registration

City of Omaha Planning Department

Permits and Inspections
1819 Farnam Street, Ste 1110
Omaha, Ne 68183
402-444-5350
Fax 402-444-5233
________________________________________________________________________

Registration is valid from issue date thru December 31st of even numbered years (unless noted).

CHECK ALL THAT APPLY REGISTRATION FEES

Class A Contractor / Class A Master Electrician (Bonded)…….. . $85.00

Class A Contractor / Class A Master Electrician (Not Bonded) …. $30.00
Journeyman Electrician…………………………………………… $30.00
Residential Journeyman Electrician………………………………. $30.00
Apprentice (Annual) ……………………………………………… $10.00

REGISTRATION FEES ARE NOT PRO-RATED

PLEASE TYPE OR PRINT ALL INFORMATION

Date ____________________________________________________________________

Applicants Full Name ______________________________________________________

First Middle Initial Last

Home Address _____________________________________ Phone ________________

City _______________________________________ State ________ Zip ___________

*State of Nebraska Electrical License Number __________________________________

~ Additional Information ~

Business Name __________________________________________________________

Business Address ________________________________________________________

City______________________________________ State ________ Zip __________

Office Phone _________________ Fax __________________ Cell _________________

E-Mail ________________________________________________________________

I hereby declare that the statements made in this application are true and correct. I acknowledge that any willful
falsification of any information herein is grounds for disqualification. I further state that I am familiar with the City of
Omaha Municipal Code chapter 44 and that I will observe these regulations.

Printed Name________________________Signature_____________________________

*NOTE: A copy of 2016-2017 State of Nebraska license must be included with this form.

INCOMPLETE APPLICATIONS WILL BE RETURNED