Electrician License Form

DBA *

Business Address *

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City

State

Zip Code

Country

Mailing Address *

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City

State

Zip Code

Country

Company Phone Number *

Contact Name *

First

Last

Business Type *

Sole Proprietor Corporation Limited Liability Company Home Occupation

Number of Employees *

State Contractor License # *

State Master License # *

Driver License # *

General Liability Policy # *

Expiration Date *

Master License Expiration Date *

State of Driver's License *

GL Expiration Date *

Have you ever been licensed with the Town of Wiggins? *

yes no

Have you ever had a license revoked? *

yes no

If yes, please explain: *

Please check each box below confirming that you have provided the Town of Wiggins with all of the following: *

Proof of property and liability insurance in the minimum amount of $250,000 per person, $500,000 aggregate, and $125,000 for property damage (a one million dollar liability / property insurance is required if the contractor will be doing work on town property or its right-of-ways / utilities State contractor’s license and state master’s license numbers

Please check each box below affirming that you have read and understand each statement. As a Town of Wiggins Licensed Contractor, and by my signature affixed hereto, I understand that: *

Applicable site-specific permits must be issued prior to commencement of any work. Construction must be completed in accordance with approved plans and the Town’s regulations. All applicable inspections related to any site-specific permit must be scheduled with the Town of Wiggins @ 970-483-6161. Building plans (if applicable), permits, and inspection records must be accessible on the job site. Job site sanitary facilities and safety measures to protect workers and the general public must be adequate. Proper supervision of all subcontractors and employees will be provided. Any changes affecting this license will be reported to the Town of Wiggins immediately. False or misleading statements on this application are grounds for disapproval or revocation of this license. The content of this application is true to the best of my knowledge and belief.

CONTRACTOR'S LICENSE

Online Form

Electrician's License

Company Information

License Information (please list the licenses you have)

Please email the following submittal requirements to hbecker@wigginsco.com.