Office Use Only: ST___________ WCI __________ WCE __________ BTR _________ Record Number_____________________________
GL___________ CORP__________ FICT __________ DL _________ Date Processed: _______________ Staff: _________
REV 06182020
Licensing Regulation & Enforcement
2725 Judge Fran Jamieson Way
Building A, Room 114
Viera, Florida 32940
Ph: 321-633-2058, op.4, op.6
Please complete the form below and provide the following:
Business name must match the business name qualified on all documents listed below.
Copy of State Certified License (actual certificate, not a summary from the state website)
Copy of Valid Driver’s License for the License Holder
Copy of Business Tax Receipt from the County/Municipality where your business is located. If located in Brevard
County, you must have a Brevard County Business Tax Receipt, call 321-264-6969 for more information.
Certificate of General Liability Insurance
Certificate of Workers Compensation Insurance (Required if you have employees)
Certificate of Workers Compensation Exemption
Certificates of Insurance must be sent directly from insurance agency with the Certificate Holder as follows:
Brevard County Licensing Regulation & Enforcement
2725 Judge Fran Jamieson Way, A-114
Viera, FL. 32940
This form and requested documents are to be emailed to:
Complete Business Name include Fictitious Name/DBA (If Applicable)
_________________________________________ _________________________________________________
First and Last Name of License Holder (Print) Florida State Certified License Number
_________________________________________ _________________________________________________
Business Phone Number License Holder Email Address
_________________________________________ _________________________________________________
Business Street Address City State Zip Code
_________________________________________ _________________________________________________
Contact Name Contact Email
I understand, as the license holder I am responsible for all work that I have contracted or permitted in Brevard
County. I further understand that if I hire or lease any employees that I must submit a Certificate of Workers
Compensation Insurance to the Contractor Licensing Agency and may be requested to provide subcontractor
information. Hired subcontractors are required to be licensed and registered for all regulated trades in Brevard
Signature of License Holder: ______________________________ Date: __________ Cell Phone: _______________
No signature stamps accepted
*For new BASS users only: Online permitting (BASS-Brevard’s Advanced Service Site) access requires a separate registration process.
The registration form and instructions for BASS will be provided once your repository application has been processed.
*Check yourself out on-line:
Check yourself out online: