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Home My Public Portal AboutRomanoff Floor Covering IncCITY OF TYBEE ISLAND CONTRACTOR REGISTRATION APPLICATION CITY OF TYKE ISLAND, -fj=.r. 7 wf u . --71:41 AM o: `ei_-iictei Tat: lOFfikr AP TFR11.2 IFQ46, 1817 ReneV I ..v i •. TZ JAN 21 �G _ate 219.88 R FLIED: R1- Business Name Romanoff Floor Covering Inc "A :` - ° Oa !Location 3100 Jonquil Drive Southeast, Smyrna, Georgia, 30080 Mailing Address 251 Little Fails Dr, Wilmington, DE 19808 Phone 770-980-1234X3021 Email Nathanielwelle@rrenovations.com r Federal ID * 5S`. i t7"t 1O' fe.7� NAICS Code Business Type (circle one): Sole Proprietor Partnership Corporation LLC Other: Inc Type of Contractor ii General 0 Electrical 0 Mechanical 0 Plumbing 0 Other Has this business or anyone connected with this business been dted or charged with any violation of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State - • ue Commissioner or any Rule or Regulation of the City or County within the past 12 months? (circle one) YES or (If YES, list details) 1. Include a cony ofyour local business license. \-/ 2. Any siness that renuires state licensing must include a copy of state license. List persons)Tauthorized to request inspections: I hereby make application to the City of Tybee Island for a Contractor Registration. I certify that the above statements are true and correct I understand that the processing fee of $20.00 is non-refundable. I further understand that the provision of false information on this application may result in the revocation of this registration by the City of Tybee Island. Applicant -Signature Printed Name Received by Date Date a/a6/a. i ROUTDIGi APPROVAL BY DATE FEE Administrator REQUIRED ContractvrRegJs#ratr'on 20.00 ZoningApprrwal { REQUIRED Reason fordeniak city of Tybee Island 403 Butler Avenue Attention: Contractor Registration, P.O. Box 2749, Tybee Island, Georgia 31328-2749 Telephone (912) 786-4573 FAX (912) 786-9539 www.cityoftvbee.orq License # Affidavit Verifying Status for City Public Benefit Application By executing this affidavit under oath, as an applicant for a City of Tybee island, Georgia, Business License or Occupation Tax Certificate, Alcohol License, Taxi Permit, Contract, or other public benefit as referenced in O.C.G.A. Section 50-36-1, the undersigned applicant representing Romanoff Floor Covering Inc (name of business), verifies one of the following with respect to my application for public benefit: 1) if I am a United States citizen. (document example: Driver's license, US Passport, US Military Card, etc.) OR 2) I am a legal permanent resident of the United States (document example: 1-551 Permanent Resident Card, Certificate of Citizenship, etc.) 3) am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency. My alien number issued by the Department of Homeland Security or other federal Immigration agency Is: I (document example: Temporary Resident Card; Employment Authorization Card, etc.) —The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least on secure and verifiable document, as required by O.C.G.A. § 50-36-1-(e), with this affidavit. The secure and verifiable document provided with this affidavit can best be classified as: In making the iiibove representation under oath, I understand that any person who knowingly and willfully makes a false, Fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and Face criminal penalties as allowed by such criminal statute. Signature of Applicant 02/25/2021 Date Nathaniel Wells Printed Name QPSstoti S00%. coo�pTARy v. • n -2 = SUBSCRIBED AND SWORN BEFORE ME ON THIS ��• pu THE DAY OF ,b , 204 4� �• 0\ *NE 11:S004e $ue` Notary Public tt1N10 My Commission Expires: q/512q PLEASE COMPLETE THIS AFFIDAVIT AND SUBMIT A COPY OF THE IDENTIFICATION DOCUMENT (front and back) PRESENT IN PERSON AT 403 BUTLER AVE OR FAX TO 912-786-9539 OR E-MAIL TO: jschaaf f cityoflybee org REFERENCE YOUR BUSINESS LICENSE NUMBER IN THE SUBJECT LINE OF YOUR E-MAIL. If fax or email this form, please have this fuiul notarized prior to submitting it to the City of Tybee Island at lscbaaf racitvoftybee.org or 912-786-9539. The City of Tybee has a notary, if submitting in person. Note: O C.G.A. § Sd-36-1(e)(2) requires that aliens under the federal Immigration and Nationallt , Ac4 7Itle 8 U.S.C, as amended provide their alien registration number. Because legal permanent residents are includod in the federal definition of "alien; legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may supply another identifying number below: 2/26/2021 2018 10 12 14 26 29 8263F3D76722FFD4325BB80E55B090DB83F(455x288) G, eorr is DRIVER'S LICENSE r=:: - • Ot. NO 057492014 ooa 09/07/1973 CLASS CM EXP 08/07/2026 4243 ROCKPOFN3 DR ffW IIVOrSAW. CAA x132 -nag G8L'n fiasni tAa ns A End NONE Is* 08/29/2018 Sex EyoiHAZ, HAt 8'-00" +ergs 1901b 0D 1368137754010049716 https://s3.amazonaws.comBucketC5416323-CBBA-46D6-8199-92F43AB12A3C/2018 10 12 14 26 29 8263F3D76722FFD4325BB80E55B090DB8... 1/1 POST IN A CONSPI9UOUS PLACE i SMYRNA GEORGIA Occupation Tax Certificate THIS LICENSE EXPIRES : 12/31/2021 ROMANOFF FLOOR COVERING INC ROMANOFF RENOVATIONS 251 LITTLE FALLS DR WILMINGTON, DE 19808 USA Category: GENERAL 1 Type: j SPECIAL TRADE CONSTRUCTION Location: 3100 JONQUIL DR SE Issue Date: Business ID: 2358 This License is NOT Transferable Business ID 2358 PAID SMYRNA GEORGIA Occupation Tax Certificate THIS LICENSE EXPIRES : 12/31/2021 Business ID 2358 ROMANOFF FLOOR COVERING INC ROMANOFF RENOVATIONS 251 LITTLE FALLS DR WILMINGTON, DE 19808 USA Category: GENERAL 1 Type: SPECIAL TRADE CONSTRUCTION Loction: 3100 JONQUIL DR SE Issue Date. Business ID: 2358 Total Received.... $11,500.00 CORPORATION ELECTION Licensee Details Licenses Information Name: Romanoff Floor Covering Inc dba Romanoff Renovations Owner: Dougle Address: 3100 Jonquil Drive SE 1 Smyrna GA 30080 Primar5i Source License Information Lic #: j RLC0003553 Profession: Residential/General Contractor Type: Residential Li Secondary: Method: Application Status: Active issued: 1/13/2014 Expires: 6/30/2022 Last Renewal Date: Associated Licenses Relationship: Supervisor Licensee: Boldt, Scott Earl License If: RLQA003572 Established: 1/13/2014 Type: ( Prerequisite User Public Board Orders Other Documents License Type: License Status: Residential Light Qualifying Agent Active Association 1/9/2014 Date: Please see Documents section below for any Public Board Orders No Other Documents Data current as of: July 3, 2020 14:58:33 This website is to be used as a primary source verification for licenses issued by the Professional Licensing Bo are avail#ble for a fee. Please contact the Professional Licensing Boards at 478-207-2440.