VILLAGE OF WAVERLY
20__ CONTRACTOR’S LICENSE APPLICATION
VILLAGE OF WAVERLY, 32 ITHACA STREET, WAVERLY, NY 14892
PHONE (607) 565-8106 / FAX (607) 565-8109
❑ NEW LICENSE
❑ RENEWAL LICENSE
LICENSE # ______ DATE _____________
BUSINESS NAME _______________________________________________________________
BUSINESS ADDRESS ___________________________________________________________
TELEPHONE (Day) ___________________________ CELL/PAGER_______________________
OWNER NAME ________________________ FEDERAL TAX ID # _______________________
1. Has the applicant been denied or license revoked by the Village of Waverly or other municipality within the last two (2) years? □ YES □ NO
If yes, explain __________________________________________________________________
2. Has the applicant been convicted of a crime or violation of Federal, State or Local Law?
□ YES □ NO If yes, provide the date, charge and court location________________________
3. Is the applicant obligated under any unsatisfied civil judgment, relating to a contract?
□ YES □ NO If yes, provide the date and court location_______________________________
4. Is the applicant aware that submission of this application constitutes authorization that the information in the application and license file shall be available to the public? □ YES □ NO
5. Does the applicant have any employees? □ YES □ NO
6. Does the applicant have any subcontractors? □ YES □ NO If yes provide names and addresses for the subcontractors. ________________________________________________
______________________________________________________________________________
State of New York)
:ss.
County of Tioga )
_____________________________________________, being duly sworn, according to law, deposes and says that the information in the application is true and correct.
_______________________________________
(Applicant’s Signature)
Sworn and subscribed before me,
A Notary Public, this _________
Day of _____________, 20_____
______________________________ Approved By:______________
(Notary Public)
-----------------------
YOU MUST ATTACH A CERTIFICATE OF INSURANCE (at least $100,000 per occurrence)
AND PROOF OF NYS WORKERS COMPENSATION COVERAGE WITH APPLICATION OR AN EXEMPTION CERTIFICATE AVAILABLE ONLINE AT WWW.wcb.. License fee is $100
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