Contractor / Sub-Contractor Registration

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Registration

Registration Year 20…

Contractors must provide a copy of their State License in order to obtain Electrical, Plumbing and/or HVAC Registrations.

Registration type

General
HVAC
Plumbing
Electrical

State License # — HVAC

State License # — Plumbing

State License # — Electrical

The undersigned hereby applies for Contractor/Sub-Contractor registration with the Pickaway County Building Department at a cost of $75.00 per registration.

Please check all supplied

Original $15,000 Bond made payable to Pickaway County as obligee. Bond must be signed by the principal, have embossed seal or surety sticker, and have an expiration date of December 31st of the registration year.
Copy of Liability Insurance with a minimum coverage of $300,000. Pickaway County must be listed as the Certificate Holder.
Copy of Workers Compensation Certificate.
State License, if required (see above).

Contact / applicant

Name

Address

City

State

Zip

Phone

Mobile

Company

Company Name

Address

City

State

Zip

Phone

Fax

Mobile

Federal ID #

Email address

It is agreed by the applicant that he/she will conform to the Rules and Regulations of the Pickaway County Resolution #PC-092908-1 and Resolution #PC110221-81, relating to the above registration(s).

Signature

Signature (sign after printing)

Date

Fees

Total fees due ($) — $75.00 per registration

Check or money order made payable to: Pickaway County Building Department.

Nothing on this page is transmitted to the county. Print it, sign it, and deliver it as the form directs.