Contractor Registration Application Form - City Of Wylie Texas printable pdf download

CONTRACTOR REGISTRATION APPLICATION

PLEASE PRINT CLEARLY

Updated September 8, 2015

Contractor Type:

Date: _____________________________

____ General Contractor

____ Mechanical

____ Electrical

____ Plumbing

____ Backflow Tester

____ Irrigation

____ Fence

____ Foundation

____ Pool Contractor

____ Energy Inspector

____ Concrete

____ Sign/Electrical

You must attach a copy of your current Master’s license, Irrigator’s license, Backflow license and a current copy of your Texas

Driver’s License. Plumbers must also attach a copy of their insurance. Backflow testers must attach a copy of their calibration

certification for their gauges that are being used.

Company Name: _____________________________________________________________________________________________

Owner/Officer/License Holder Name: ______________________________________________Title:___________________________

Officer of the company is the President, Vice President or CEO. License Holder is the person who holds the Texas State Plumber,

Mechanical or Electrical License. This person will be held responsible for seeing that all work being performed under this

registration is completed and in compliance with the City codes and ordinances.

Address: ____________________________________________City:_____________________State:___________Zip:__________

Office Number: _____________________________Fax:_____________________________Cell:___________________________

Email Address: ________________________________________________________________________________________________________

Personnel authorized to obtain a permit under this company name: (use company letterhead for additional names):

______________________________

____________________________________________

_________________________________________

Original Signature of Owner, officer or License Holder

Printed name of Owner, Officer or License Holder

This form must be notarized if any other person is registering for you or if you are registering by mail. If registering by

mail, you must include a self-addressed stamped envelope to receive a receipt of payment by return mail. Registration is

valid from January 1 through December 31. REGISTRATION FEE IS $100.00 PER LICENSE BEING REGISTERED.

NO RENEWAL NOTICE WILL BE SENT.

The State of Texas

County of_____________________§

BEFORE ME, the undersigned authority, on this day personally appeared ___________________________________known to me to be the

person whose name is subscribed to the foregoing instrument and, being by me the first duly sworn, upon oath declared that the statements and

capacity acted in are true and correct.

_____________________________________________

Signature

_____________________________________________

Title

Subscribed and sworn to before me, this_________day of__________________20______A.D. to certify which witness.

__________________________________________

Notary Public - Signature

City of Wylie Texas – 300 Country Club, Bldg. 100, Wylie, TX 75098 –

972-516-6420

Contractor Registration Application Form - City Of Wylie Texas

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