contractors

Planning and Building

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APPLICATION DATE	12/07/2023
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CONTRACTOR / BUSINESS INFORMATION
CONTRACTOR LICENSE CATEGORY / TYPE *	/
CONTRACTOR / BUSINESS NAME *
ADDRESS 1 *
ADDRESS 2
CITY *
STATE *
ZIPCODE *
PHONE ( XXX-XXX-XXXX )
CELL PHONE ( XXX-XXX-XXXX ) *
PRIMARY EMAIL *
SECONDARY EMAIL
EXAMINEE INFORMATION
EXAMINEE NAME *
EXAMINEE ADDRESS
EXAMINEE CITY
EXAMINEE STATE
EXAMINEE ZIPCODE
EXAMINEE PHONE ( XXX-XXX-XXXX ) *
PRINCIPAL / OWNER INFORMATION
PRINCIPAL NAME / TITLE *	/
PHONE ( XXX_XXX_XXXX ) *
DRIVERS LICENSE NUMBER / ISSUING STATE *	/
DRIVERS LICENSE EXPIRATION DATE ( MM/DD/YYYY ) *
DRIVERS LICENSE DOCUMENT	Upload Image
OTHER CURRENT LICENSES ( COMMA SEPERATED LIST )
BOND / INSURANCE INFORMATION
BOND NUMBER *
BOND EXPIRATION DATE ( MM/DD/YYYY ) *
LAKE COUNTY RECORD NUMBER
BOND DOCUMENT	Upload Image
LIABILITY POLICY CARRIER *
LIABILITY POLICY CARRIER PHONE ( XXX-XXX-XXXX ) *
LIABILITY POLICY NUMBER *
LIABILITY EXPIRATION DATE ( MM/DD/YYYY ) *
LIABILITY INSURANCE DOCUMENT	Upload Image
WORKMAN COMPENSATION POLICY CARRIER *
WORKMAN COMPENSATION POLICY CARRIER PHONE ( XXX-XXX-XXXX ) *
WORKMAN COMPENSATION POLICY NUMBER OR EXEMPT *
WORKMAN COMPENSATION EXPIRATION DATE ( MM/DD/YYYY ) *
WORKMAN COMPENSATION DOCUMENT	Upload Image
ONLY REQUIRED IF APPLICATION IS FOR A PLUMBER'S CONTRACTOR LICENSE
STATE LICENSE NUMBER
STATE LICENSE EXPIRATION DATE ( MM/DD./YYYY )
STATE LICENSE DOCUMENT	Upload Image
SIGNATURES

UPLOAD SUPPORTING DOCUMENTATION	Upload Supporting Documentation
APPLICANT E-SIGNATURE *	(Typed name indicates agreement / electronic signature that submitted information is true and accurate.)
ENTER CAPTCHA PHRASE EXACTLY AS SHOWN *	65Nmg2

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