ALMONT TOWNSHIP BUILDING DEPARTMENT



ALMONT TOWNSHIP BUILDING DEPARTMENT

819 N. MAIN STREET

ALMONT, MICHIGAN 48003

PHONE 810-798-8521 / FAX 810-798-7097



CONTRACTOR’S REGISTRATION FORM

REGISTRATION NUMBER: ____________________ REGISTRATION FEE: $___ 15.00___________

(To be completed by Twp. Official) (Registration is valid until expiration date of license.)

NAME OF BUSINESS/COMPANY/PERMIT HOLDER:

NAME OF CONTRACTOR: /MASTER PLUMBER:

STREET ADDRESS:

CITY, STATE, & ZIP:

(Office and/or Cell)

PHONE NUMBER : / FAX PHONE NO.

MASTER TRADE LICENSE NUMBER: EXPIRATION DATE:

CONTRACTOR TRADE LICENSE NUMBER: (Must provide photo copy of State issued license)

LICENSE CLASSIFICATIONS (Mechanical)

NAME OF ANY OFFICERS/OWNERS/AGENTS OF BUSINESS/COMPANY LISTED ABOVE WHO ARE AUTHORIZED AGENTS OF SAID BUSINESS/COMPANY TO APPLY FOR PERMITS AND/OR SCHEDULE INSPECTIONS:

FEDERAL EMPLOYER I.D. NUMBER (OR REASON FOR EXEMPTION):

WORKER’S COMP. INSURER (OR REASON FOR EXEMPTION):

MESC EMPLOYER NUMBER (OR REASON FOR EXEMPTION):

DRIVER’S LICENSE NUMBER:

(Must provide photo copy of valid driver’s license):

“SECTION 23a OF THE STATE CONSTRUCTION CODE ACT OF 1972, ACT NO. 230 OF PUBLIC ACTS OF 1972, BEING SECTION 125.152a OF THE MICHIGAN COMPLIED LAWS, PROHIBITS A PERSON FROM CONSPRIING TO CIRCUMVENT THE LICENSING REQUIREMENTS OF THIS STATE RELATING TO PERSONS WHO ARE TO PERFORM WORK ON A RESIDENTIAL BUIDING OR A RESIDENTIAL STRUCTURE. VIOLATIONS OF SECTION 23a ARE SUBJECT TO CIVIL FINES.”

I, THE UNDERSTATED, HAVE READ AND UNDERSTAND THE ABOVE PUBLIC ACT AND WILL ABIDE BY THIS LAW.

(Print Applicant’s Name)

(Applicant’s Signature)

Effective 5/1/2009 (Name of Firm or Company)

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