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APPLICATION AND RENEWAL
CONTRACTOR'S LICENSE

DATE:

______________________________________________
   

APPLICANT'S NAME:

__________________________________________________________________
   

HOME ADDRESS:

__________________________________________________________________
           

CITY:

_______________________

STATE:

___________

ZIP:

___________
         

HOME PHONE NUMBER:

_______________________

EMAIL__________________________
         

COMPANY NAME:

______________________________________________

 

 
     

COMPANY ADDRESS:

______________________________________________

 
           

CITY:

_______________________

STATE:

___________

ZIP:

___________
       

BUSINESS PHONE NUMBER:______________________

 

 

 
           

CELL PHONE

______________________

FAX:

___________

 

 
   

TYPE OF CONTRACTOR:

__________________________________________________________________
   

YEARS OF EXPERIENCE:

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EXPERIENCE RECORD

NAME (CONTRACTOR)

ADDRESS

PHONE

YEAR
       

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_____________________________

_________________

_____
       

_____________________________

_____________________________

_________________

_____
       

_____________________________

_____________________________

_________________

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I, THE UNDERSIGNED, HEREBY DEPOSE AND SAY THAT ALL THE STATEMENTS ON THIS APPLICATION ARE TRUE. I WILL BE RESPONSIBLE FOR COMPLIANCE WITH ALL ORDINANCES AND LAWS IN EFFECT GOVERNING WORK PERFORMED UNDER PERMITS ISSUED BY THE CITY OF MISHAWAKA.

___________________________________________

(SIGNATURE OF APPLICANT)

Click to print out your Plumbing Permit Application Form.

 

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