Application For Contractor'S Registration/license - Borough Of Eddystone
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BOROUGH OF EDDYSTONE
APPLICATION FOR CONTRACTOR’S REGISTRATION/LICENSE
1300 EAST 12TH STREET, EDDYSTONE, PA 19022 PHONE (610) 874-1100
FAX (610) 874-1605
LICENSE FEE is $50.00 (Make checks payable to the Borough of Eddystone) _
COMPLETE ALL FIELDS ON THIS APPLICATION FORM (PRINT LEGIBLY); ALSO PROVIDE NOTARIZED SIGNATURE AND VALID
CERTIFICATE OF INSURANCE. CONTRACTOR’S LICENSE SHALL BE VALID FROM THE DATE OF ISSUANCE TO THE END OF THE
CALENDAR YEAR. LICENSE APPLICATION AND WORK PERMIT APPLICATIONS MUST BE APPROVED PRIOR TO STARTING ANY
WORK. INFORMATION - WORK PERMIT FEE’S ARE $30 PER EVERY $1000 OF PROJECT L&M COSTS, UP TO $50,000. ABOVE $50,000
THE FEE IS $15 PER EVERY $1000 OF PROJECT L&M COSTS. AMENDED AND APPROVED BY ORD. No. 546 ON 10/12/1990.
APPLICANT’S NAME______________________________________________DATE___________________
APPLICANT’S TITLE _______________________________________ BIRTH DATE __________________
CONTRACTOR CLASSIFICATION
(CIRCLE APPLICABLE DISCIPLANES)
GENERAL
ELECTRICAL
PLUMBING HVAC FIRE (SPRINKLER) ROOFING/SIDING
OTHER_________________________________________________________________________________
BUSINESS TYPE
(CIRCLE ONE)
INDIVIDUAL,
PARTNERSHIP,
CORP,
INC.
LLC
BUSINESS NAME__________________________________________________________________________
BUSINESS ADDRESS_______________________________________________________________________
FED TAX ID #_________________________ OR
SOCIAL SECURITY #__________________________
BUSINESS PHONE #____________________ FAX # __________________CELL #_____________________
YEARS IN BUSINESS: _____ PREVIOUSLY LICENSED IN EDDYSTONE (Y/N): _____ YEAR_________
OTHER MUNCIPALITY LICENSES ___________________________________________________________
(For Plumbing, Provide Delaware County Municipal Plumbers Council - DCMPC ID #)
REQUIRED IS A COPY OF CONTRACTOR’S CERTIFICATE OF INSURANCE WITH THE
BOROUGH NAMED AS A CERTIFICATE HOLDER.
GENERAL LIABILITY AND WORKER’S COMPENSATION INFORMATION:
(Contractors without employees
performing work may claim exemption by stating EXEMPT - NO EMPLOYEES below and signing in presents of Notary)
___________________________________________________________________________________________
GL & WC Insurers name, Insurers address, Policy #, Policy expiration date
__________________________________________
SEAL
APPLICANT SIGNATURE
Sworn to and subscribed before me
this_______________ day of___________, 20_____
Notary public Signature__________________________ My Commission Expires ______________
*******************************************************************************************
Do not write in this area. (To be approved by Eddystone Appropriate Agent)
SIGNATURE OF APPROVAL: ________________________________________DATE:___________
Eddystone Borough Contractors Registration Form – Rev 0 – 02/03/06
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