HomeMy Public PortalAboutContractor-Registration FormTown of Gulf Stream
Building Department • 100 Sea Road., Gulf Stream, Florida 33483
Website: www.gulf-stream.org • Phone: 561-276-5116 • Fax: 561-448-1009
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NAME OF BUSINESS:
OFFICE ADDRESS: CITY/STATE/ZIPCODE:
CELL NO.:
EMAIL ADDRESS:
OFFICE TELEPHONE NO.:
FAX NO.:
QUALIFER INFORMATION:
NAME OF QUALIFIER:
OFFICE ADDRESS: CITY/STATE/ZIP CODE:
OFFICE TELEPHONE NO.: CELL NO.:
EMAIL ADDRESS:
FAX NO.:
LE8,SE INCLUDE COPIES OF THE FOLLOWING DOCUMENTS:
State License (F.S. 489.115) or Palm Beach County Certificate of Competency and State Registration
County Business Tax Receipt
[1 Liability and Worker's Compensation Certificates of Insurance made out to the Town of Gulf Stream
Worker's Compensation Exemption, if applicable
Qualifiers must produce a legible Government Issued Identification with picture
Vehicle Registration of any commercial vehicles that will be at the jobsite
I hereby acknowledge and certify that the information contained herein is true and accurate to the best of my
knowledge.
Qualifier Signature Date
Qualifier Print Name Legibly
08/2022