August 2016
CITY OF TULSA
DEVELOPMENT SERVICES – PERMIT CENTER
175 E 2
nd
St, SUITE 455, TULSA, OK 74103
Hours: 8 am to 4 pm
ACCOUNT INFORMATION AND CONTRACTOR REGISTRATION
Account No. Date:
Company Name (Full Legal):
Corporate Officer: Position held in Company:
Company Address:
Company Mailing Address:
Phone: ( ) FAX: ( )
Mobile Phone: ( ) E-mail Address:
Name of Owner: Phone: ( )
Address of Owner: E-mail Address:
CONTRACTURAL AGREEMENT: As partial consideration for this account, when insurance is required,
contractor/account holder agrees, in part, to provide proof of general liability insurance in the amount required
by law which names the City of Tulsa as an Additional Insured and provides 30 days prior written notice of
cancellation to the City.
Authorized Signature:
LICENSEE INFORMATION (For License Registration Only)
TRADES:
Building Mechanical Plumbing Electrical Comm. Fire Sprinkler Fire Alarm House Mvg
Demolition Portable Fire Extinguisher Pre-Eng. Fire Suppression Sys. Eng. Fire Suppression Sys.
Sidewalk & Driveway* Paving Cut* Other:
*Requires an Annual Contractor’s Contract with City of Tulsa. See Infrastructure Development Process Manual.
Last Name: First Name: MI: Title:
State Control # (if applicable): Expiration:
License Type(s):
Affidavit as to Licensee Information
I, __________________________________________, being duly sworn upon oath, state that I am the licensed contractor and
will be doing business as _________________________________________________________________________________.
____________________________________________________________
Signature of Licensed Contractor
Subscribed and Sworn to Before Me this ________ Day of _________________________________, ________.
____________________________________________________ My Commission Expires: _________________________________
Notary Public
