Levy County State Certified Contractor Registration

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Levy County State Certified Contractor Registration Powered By Docstoc
					              LEVY COUNTY BUILDING DEPARTMENT
                       APPLICATION FOR
                 STATE CERTIFIED CONTRACTOR


 DATE:


 LICENSE HOLDERS NAME:


BUSINESS NAME:


TYPE OF LICENSE:


LICENSE #                                    EXPIRATION DATE:


ADDRESS:


PHONE    #(l__             CELL PHONE     #( )            FAX   #(   )




CONTRACTOR/AGENT PRINT



CONTRACTOR/AGENT SIGNATURE

SUBMIT THIS APPLICATION WITH THE FOLLOWING:

COPY OF STATE CERTIFICATION CARD
COPY OF LIABILITY INSURANCE
COPY OF WORIGRS COMPENSATION INSURANCB OR
WORI(ERS COMPENSATION EXEMPTION CARI)
COPY OF DRIVERS LICENSE/PICTURE I.D.

S2O.OOIRECORDS MANAGEMENT FEE
(Make Checks Payable to: Board of Counfy Commissioners)
MAIL TO: Post Office Box 672 Bronson, Florida 32621
PHONE #(3s2)486-s204 - FAX # (3s2\486-s246
ATTENTION: KTM
EMAIL: Iewlicense@vahoo.com

				
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