Contractor Registration Application

OFFICE USE ONLY
DATE APPLICATION RECEIVED EXPIRATION DATE
REGISTRATION NUMBER FEE $100 for 2 Year Registration

COMPANY NAME

BUSINESS ADDRESS

PHONE # EMAIL #

LICENSEE NAME OR APPLICANT

Electrical General Contractor Plumbing Other

Inc. Village of East Rockaway listed as additional insured on insurance certificates

Liability Insurance: ACORD 25 Form
Worker's Compensation Insurance: Certificate C-105.2
Disability Certificate: DB-120.1
Nassau County Home Improvement License
Town of Hempstead Master Plumber or Master Electrician License (if applicable)

Signature Date

J:BUILDING DEPARTMENT\East Rockaway License\Building Department Contractor Registration Application