Contractor Registration Form

Name of Business*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Owner's Name*

First Last

Phone*

Fax

Email*

General Contractor (if applicable)

Job Site*

REQUIREMENTS & FEES*

General Contractor-$100.00
Contractors & Subcontractors (per trade)-$50.00

ALL GENERAL CONTRACTORS MUST SUBMIT:1) A signed original $10,000.00 Surety Bond.2) Certificate of Insurance w/General Liability of $500,000/Auto $500.000/Workers Comp $500.000All Sub Contractors Must Submit: Exception Plumbers and Roofers1) A signed original $5000.00 Surety Bond.2) Certificate of Insurance w/General Liability of $500.000/Auto $500.000/Workers Comp $500.000

List Trades

Surety Bond Expiration*

Certificate of Insurance Expiration*

State of Illinois Roofing License Expiration*

State of Illinois Plumbing License Expiration*

I HEREBY DECLARE THAT ALL OF THE ABOVE INFORMATION GIVEN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AGREETO COMPLY WITH ALL VILLAGE AND STATE CODES, ORDINANCES AND LAWS NOW IN FORCE AND ANY OTHERS THAT MAY BEENACTED DURING THE DURATION OF REQUESTED LICENSE. I FURTHER UNDERSTAND THAT DURING THIS LICENSING PERIOD,SHOULD ANY OF THE REQUIRED INSURANCE/LICENSING DOCUMENTS EXPIRE, THIS LICENSE BECOMES NULL AND VOID.

Signature

Patrick Brennan, Village President