Complete the DECLARATION OF LICENSE ASSIGNMENT form and return it to:
ST. LOUIS COUNTY BUILDING COMMISSION’S BOARD OF PLUMBERS AND DRAINLAYERS EXAMINERS 41 South Central Avenue - 6th Floor Clayton, Missouri 63105
If you have any questions, call 615-3741.
ST. LOUIS COUNTY BUILDING COMMISSION’S BOARD OF PLUMBERS AND DRAINLAYERS EXAMINERS ST. LOUIS COUNTY, MISSOURI
DECLARATION OF LICENSE ASSIGNMENT
Business Name Address
(no. & street) (city) (state & zip)
Business Phone (
)
-
Fax No. (
)
-
FEDERAL ID NUMBER: CORPORATION ID NUMBER:
(if corporation)
I am licensed, registered, or certified as: (please check only one) _______ Master Plumber _______ Master Drainlayer _______ Master Pipefitter _______ Master Sprinklerfitter _______ Master Lawn Irrigation System Installer _______ Master Water Heater Replacement Specialist Licensee Name
(last) (first) (mi)
Social Security Number Home Address
(no. & street)
-
-
(city)
(state & zip)
Home Phone (
)
-
I do hereby certify that I am a full-time employee of the above mentioned company/corporation, during their regular business hours, and that I am in a position to act on behalf of the company/corporation in all matters pertaining to the Plumbing License Code and Ordinance requirements of the license which is held by me. I will notify the St. Louis County plumbing licensing office immediately if I should leave the above mentioned company/corporation, or if there are any changes in the above information.
Date
Signature
PW-DeclarLicAssign-01/01