Contractor Record Maintenance Form
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1City of Pompano Beach
Department of Development Services
Business Tax Receipt Division
Contractor Record Maintenance
100 W. Atlantic Blvd Pompano Beach, FL 33060
Phone: 954.786.4668 / 954.786.4633 Fax: 954.786.4666
NO PERMIT WILL BE ISSUED WITHOUT THE COMPLETION AND APPROVAL OF
THIS APPLICATION.
Business name________________________________________________________
Business address______________________________________________________
City___________________________________ Zip________________
Email_________________________________________________________________
Business phone____________________________
Number of Employees ________
Qualifier’s name_______________________________________________________
Home address_______________________________________________________
City____________________________________ Zip______________
Email_______________________________________________________________
Home phone_______________________________
If you hold a Broward County Competency Card, the following items must be submitted:
A copy of your Broward County Certificate of Competency and State Registration (if
applicable) (FS 489.115)
A copy of your Broward County Business Tax Receipt (County Ordinance 20.15)
A copy of your Liability and Worker’s Comp Insurance, the City of Pompano Beach
must be the certificate holder (City of Pompano Beach, P.O. Drawer 1300, Pompano Beach, FL
33061) (FS 489.114 and FS 489.115)
A copy of your Worker’s Comp Exemption (if applicable) (FS 440.10)
If you hold a State Certification, the following items must be submitted:
A copy of your State Certification (FS 489.115)
A copy of the applicable County Business Tax Receipt where business is located (City
Ordinance 111.03)
A copy of your Liability and Worker’s Comp Insurance, the City of Pompano Beach must
be the certificate holder (City of Pompano Beach, P.O. Drawer 1300, Pompano Beach, FL 33061)
(FS 489.114 and FS 489.115)
A copy of your Worker’s Comp Exemption (if applicable) (FS 440.10)
NOTE: For more than one qualifier, please complete one form for each qualifier.
There is a $20 annual record maintenance fee for each competency card or state license. Contractor Record
Maintenance is a service the City provides for you to place your credentials on file. This will allow you to pull
permits with the City without having to produce your ORIGINAL credentials each time you apply for a permit
(City Ordinance 111.03).
Modified: 9.29.14
G:\Zoning 2009\Forms and Sample documents\Website Documents\BTR\Applications\contractor_registration.pdf
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