1784Bd61 Contractor Registration Form 2.19.20 2¶
| Field | Value |
|---|---|
| Category | Permits & Municipal > Permits & Applications |
| Confidence | high |
| Reason | Contractor registration form for building permits issued by City of Brookhaven |
| Original File | 1784bd61_contractor_registration_form_2.19.20_2.pdf |
| File Type | |
| Source | gmail-export |
Document¶
Full Text (OCR)
Contractor Registration CONTACT INFORMATION
Business Name: Email Address:
Address:
Suite:
City: State:
Zip:
Office Phone:
Cell Phone:
BUSINESS LICENSE INFORMATION
Business License Number
Exp.
Jurisdiction STATE LICENSE INFORMATION
Name on State Company/Individual License State License Number
Exp.
Name of Qualifying Agent Qualifying Agent License Number
Exp.
Authorized Permit Agent OPEN PERMITS — include subcontractor trade permits related to building permits Permit Number
Site Address
NOTICE:
"Contractors must provide current license information, which will be verified prior to account approval. "
State law requires that building and trade permits be issued only to contractors holding current required state licenses or to an Authorized Permit Agent.
"Contractor is responsible for providing updated license information when license is renewed. ="
The contractor to whom the permit is issued is responsible for the project.
="
Arequest for change in contractor must be submitted to the Building Official in writing stating reason, and a fee paid, before the permit will be re-issued to a new contractor.
Signature
Date
Email completed form with copies of licenses to permits@brookhavenga.gov.