Plumbing Contractor Application For Registration Or Renewal
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1
2State of Illinois
Illinois Department of Public Health
Plumbing Contractor
Application for Registration or Renewal
Print legibly or type
Business Name ____________________________________________________________________________________
Address __________________________________________________________________________________________
City ________________________________ State ______ County ___________________ ZIP code + 4 _____________
Telephone ______________________ Fax _______________________ FEIN OR SSN (#) _______________________
(Required)
Facility Mailing Address (if different from above)
Address __________________________________________________________________________________________
City ________________________________ State ______ ZIP code + 4 ______________
Confirmation of Employees
(One selection must be marked)
❑ Yes ❑ No
Do you have any employees (clerical, janitorial, plumbers, etc.) beside yourself? If yes, you are required
to have $500,000 Workers’ Compensation coverage on your Certificate of Insurance. If no, you must
complete the enclosed Affidavit of No Employees.
Type of Ownership
(One selection must be marked)
❑ Sole Proprietorship (Sole owner must be a licensed plumber.)
❑ Partnership (One of the partners must be a licensed plumber.)
List names, addresses and telephone numbers of each general partner.
❑ Corporation/Limited Liability Company (LLC)
List the exact full name of the corporation or limited liability company as on file with the Secretary of State.
List name, address and telephone number of the corporation or limited liability company’s registered agent.
Complete the following information for the Licensed Plumber of Record: (The Plumber of Record must be the sole
owner, if sole proprietor; a partner, if partnership; an officer, if a corporation; or a manager/member, if LLC.)
Name of Plumber _________________________________________ Telephone Number ________________________
Address __________________________________________________________________________________________
City ________________________________ State ______ County ___________________ ZIP code + 4 _____________
Plumbing License ID #________________________________ Plumbing License Expiration Date___________________
$150 annual registration fee (Registration fees are non-refundable.)
***__________________________________________________
_____________________
Original Signature of Plumber of Record
Date
FEES ARE NON-REFUNDABLE
Renewal Fee: $150
Reinstatement/Late Fee:$100
Returned Check Fee:$200
APPLICATION INSTRUCTIONS AND REQUIRED ATTACHMENTS LISTED ON REVERSE SIDE
IL 482-0679
Printed by Authority of the State of Illinois
IOCI 15-479
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