Standardized Business LicenseApplication

City orCounty:


BusinessInformation

Corporatename:

Name showntopublic:Opendate:

Organizationtype:SoleproprietorLLCLLPLPCorporation

Articles of Organization or Incorporation may berequired.

Businessactivity/type: / NAICS/SIC/Othercode:
Federal ID/SSN#: / State retail sales#:

Mailing address: Physicaladdress:

Contact name,title:

Inside jurisdiction, Tax parcel#:

Outsidejurisdiction

Contactphone:Ext. / Alternatephone:
Fax: / Email:

Owner or Principal(s)Information

Owner orPrincipal(s) name(s),title(s):

SSN#: SSN#:

Driver’slicense #:State:Expirationdate:Mailingaddress:

Job/ProjectInformation

Projecttype: / Newconstruction / Renovation / Other
General contractorname:
State contractor license#: / State: / Expirationdate:

Copy may berequired

Master/specialty license#:

Total gross revenues or contract amount:$

Gross revenues, inside jurisdiction:$ / Gross Revenues, outside jurisdiction:$
Value of authorized deductions:$ / Deductiontype(s):

OtherInformation

YesNo / Buying an existing constructionbusiness?
If yes, purchased business’name:
YesNo / Business leasing space to anotherbusiness?
YesNo / Mailbusinesslicenserenewalstomailingaddresslistedinthebusinessinformationsectiononthepreviouspage?
If not, corporateaddress:
YesNo / Change of use tobuilding?
YesNo / Erecting a newsign?
YesNo / Existing business with no priorlicense?
YesNo / Homeoccupation?
YesNo / Independent contractors (Form1099)?
If yes,names:
YesNo / Leasingproperty?
If yes, landlord name andaddress:
YesNo / Restrictive covenants? If yes, providecopy.

ApplicantCertification(Contactthemunicipalityinwhichyouaredoingbusinesstodetermineifanotarizedsignature isrequired.)

1.Iherebycertifythatallinformationprovidedistrueandcorrecttothebestofmyknowledgeandthatthegrossrevenueis accurately reported or estimated for a new business without any unauthorizeddeduction.

2.Icertifythatassessments,delinquenciesandpersonalpropertytaxesduetothejurisdictionarefullypaid.

3.Iunderstandthatprovidingfalseorfraudulentinformationmayresultinpenalties,businesslicenserevocationand/or prosecution to the fullest extentpossible.

4.Iamawareofandunderstandthejurisdiction’srequirementsandcodes,and theissuanceofabusinesslicenseiscontingent upon strict and consistent compliance with all of the jurisdiction’srequirements.

5.Iunderstandthatfailuretocomplywiththeserequirementsmayresultinbusinesslicenserevocationaswellasother compliance or legalefforts.

6.I also understand and authorize the jurisdiction and its agents to utilize all information on this application to ensure that all other federal, state and local laws are compliedwith.

Applicantprintedname:Signature:

Title:Date:

For Office UseOnly

Approved by all necessary departments? Yes No
Comments
Approved? Yes No / Date:
Business license# / Rateclass:
Rate Base rate:$ / Every $1,000 after:$
Amount due Fee:$ / Penalties:$ / Total:$
Decal required? Yes No / Cost/each:$ / Total:$
Receipt Amount paid:$ / Datepaid: / Number ofdecals:
Staffname: / Signature: / Date: