Building & Zoning Division New Contractor Registration Application And Contractor'S Affidavit Form Page 2
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1
2B
& Z
D
UILDING
ONING
IVISION
N
C
R
A
EW
ONTRACTOR
EGISTRATION
PPLICATION
A
C
’
A
ND
ONTRACTOR
S
FFIDAVIT
Registration is voluntary for State Registered or State Certified Contractors.
It is required for Specialty Tradespersons. This form must be completed,
the affidavit sworn (or affirmed) and notarized.
th
Registration starts October 1st and expires on September 30
every 2 years.
Instructions appear on the other side of this form
License Holder’s Name
__________________________________________________________________________
Name of the Business (DBA)
__________________________________________________________________________
Mailing Address
___________________________________________
City, State, ZIP _________________________
Business Address
___________________________________________
City, State, ZIP _________________________
Business Telephone Number
__________________________________
Fax Number ____________________________
Cellular Telephone Number
__________________________________
E-mail ________________________________
Type of Contractor ___________________________________________
State License __________________________
C
’
A
ONTRACTOR
S
FFIDAVIT
U
, I, ______________________________,
(
)
NDER OATH
HEREBY SWEAR
OR AFFIRM
THAT ALL INFORMATION
;
/
PROVIDED HEREIN IS ACCURATE AND COMPLETE
THAT ALL FORMS AND
OR COPIES ATTACHED ACCURATELY
;
REPRESENT THE ORIGINALS AND HAVE NOT BEEN ALTERED IN ANY WAY
THAT I SHALL ASSURE UNDER PENALTY OF
F
S
§440.05
LAW THAT ANYONE HIRED TO WORK ON MY BEHALF SHALL EITHER BE EXEMPT UNDER
LORIDA
TATUTE
OR
W
’
C
I
(
F
S
§440.10
BE COVERED BY
ORKER
S
OMPENSATION
NSURANCE
AS PROVIDED IN
LORIDA
TATUTES
AND
§440.38);
I
,
,
I
THAT
SHALL ABIDE BY ALL LAWS
ORDINANCES
STATUTES AND CODES APPLICABLE TO THE WORK
PERFORM AND THAT ALL WORK PERFORMED BY ME OR ON MY BEHALF SHALL CONFORM TO ALL APPROPRIATE
.
BUILDING CODES AND STANDARDS
Signature of License Holder ____________________________________________
___________________
Date
This oath must be Sworn (or Affirmed) by a Notary Public. The space below is for his or her use ONLY.
STATE OF FLORIDA, COUNTY OF _______________
Sworn to (or affirmed) and subscribed before me this _____ day of ________, 201__, by _____________________________________
Contractor Name
Place Notary Seal Below:
___________________________________________________
(Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of NotaryPublic)
Personally Known [ ] OR Produced Identification [ ]
Type of Identification Produced ________________________
If you wish to use one or more Authorized Agents, please also
.
complete, sign and submit the Agent Authorization Form
Contractor Registration Application
B34.12-03
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