Fillable CONTRACTOR CLASS CERTIFICATION APPLICATION (HERNANDO COUNTY BUILDING DIVISION)

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CONTRACTOR CLASS CERTIFICATION APPLICATION (HERNANDO COUNTY BUILDING DIVISION)

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HERNANDO COUNTY BUILDING DIVISION
Contractor Licensing
789 Providence Blvd.
Brooksville, FL 34601
(352) 754-4050
CONTRACTOR CLASS CERTIFICATION APPLICATION
Alarm I & II General Sheet Metal
Building Mechanical Solar
Class A Air Conditioning Plumbing Swimming Pool Service
Class B Air Conditioning Residential Underground Utility
Commercial Pool Residential Pool
Electrical Unlimited Roofing
__________________________________________________________________________________________
The Hernando County Board of Construction & Regulation has established criteria for obtaining a
Certificate of Competency in Hernando County as defined under Hernando County Ordinance 2015-11
1. Proof of a proctored examination administered and proctored by a Florida testing firm
with a minimum test score of 75 percent on both sections.
2. In order to verify an applicant's experience, the applicant will be required to provide
evidence of a minimum of four (4) years active experience in the trade within the last
eight (8) years immediately preceding the filing of the application from practicing
contractors in the field for which the applicant is applying, or from contractors
possessing a more qualified license.
Applicants for Unlimited Electrical must include 40% in Phase 3 experience.
Applicants for Alarm Contractor I must include 40% fire alarm experience
Applicants for Alarm contractor II must include 40% work in alarm systems other than
fire.
Such evidence shall be in the form of a least two (2) notarized documents (supplied
with application) which show proof of the required years active experience. Such
experience must meet the criteria as set forth by Board Rule. THE SUPPLIED
FORMS MUST BE USED IN DOCUMENTING YEARS OF EXPERIENCE.
3. A business and personal financial statement must be supplied for those contractors/
subcontractors already duly licensed in another county. Only a personal financial
statement will be required for an applicant not currently duly licensed in any local
jurisdiction.
1
4. A business and personal credit report from a state approved credit bureau. The reports
MUST be mailed DIRECTLY to CONTRACTOR CERTIFICATION from the credit
bureau. It is the applicant's responsibility to request this report from the credit bureau.
For an applicant not currently, duly licensed in any local jurisdiction, only a personal
credit report will be necessary.
5. A background check will be done on all applicants. There is a non-refundable
application/background check fee due when you submit your application to this
office. Contact the Building Division for current fees.
6. As an applicant if your application is denied you may appeal, and appear before the
Board of Construction & Regulation.
7. If appearance before the Board of Construction & Regulation is requested or
required and your application is denied, You must wait 6 months before reapplying.
All applications must be completed in their entirety and submitted to Contractor Certification.
IF YOUR APPLICATION IS RECEIVED INCOMPLETE, YOU WILL BE NOTIFIED OF
WHAT IS NEEDED TO COMPLETE IT. INCOMPLETE APPLICATIONS WILL NOT
BE CONSIDERED. THERE WILL BE NO EXCEPTIONS.
There is a non-refundable application/background check fee due when you submit your application
to this office. Contact the Building Division for current fees.
If your application is approved, there will be an additional fee for the competency card. This amount
is not due until your application is approved. All checks are to be made out to the Hernando County
Building Division. Contact the Building Division for current fees.
Within thirty (30) days of Department approval the following items must be supplied to Contractor
Certification. FAILURE to supply the following items will result in your application being voided
and all monies forfeited.
1. Liability Insurance in the applicable amount; (Hernando County must be listed as a certificate holder).
General Contractor 300,000 50,000
Building Contractor 300,000 50,000
Residential Contractor 100,000 25,000
Alarm I & II Contractor 300,000 500,000
Commercial Pool Contractor 100,000 25,000
Residential Pool Contractor 100,000 25,000
Sheet Metal Contractor 100,000 25,000
Underground Utility Contractor (Excavation) 100,000 25,000
Plumbing Contractor 100,000 25,000
Roofing Contractor 100,000 25,000
Mechanical Contractor 100,000 25,000
Solar Contractor 100,000 25,000
2
Class A Air conditioning Contractor 100,000 25,000
Class B Air Conditioning Contractor 100,000 25,000
Electrical Unlimited Contractor 300,000 500,000
Swimming Pool Service Contractor 100,000 25,000
3. Workers' compensation or valid Workers' Compensation Exemption.
4. State Registration (if applicable).
APPLICANTS ARE REMINDED THAT THEY MAY ONLY CONDUCT BUSINESS IN
THE NAME WHICH APPEARS ON THEIR CERTIFICATE OF COMPETENCY AND
REGISTRATION.
If you are not registered with the State at the time you pick up your certificate of competency and are
required to do so, you will be given a thirty (30) day grace period within which to become registered.
Be advised your application for a certificate, including all information submitted in conjunction with
your application, is subject to Florida State Statute 119.07 (public records law).
119.07 Inspection, examination, and duplication of records; exemptions which reads:
(1)(a) Every person who has custody of a public record shall permit the record to be
inspected and examined by any person desiring to do so, at any reasonable time,
under reasonable conditions, and under supervision by the custodian of the public
record or his designee.
PLEASE BE ADVISED
APPLICATIONS ARE VALID FOR A PERIOD OF 180 DAYS.
APPROVED APPLICATIONS ARE VALID FOR A PERIOD OF SIXTY DAYS.
3
CHECKLIST
PLEASE NOTE: THE FOLLOWING ITEMS MUST BE COMPLETED AT THE TIME YOU
SUBMIT YOUR APPLICATION TO CONTRACTOR CERTIFICATION. THE APPLICATION
WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE COMPLETED.
ALL APPLICATIONS MUST BE TYPED OR PRINTED LEGIBLY
_____(1)
_____(2)
_____(3)
_____(4)
_____(5)
_____(6)
_____(7)
_____(8)
_____(9)
My Business and Personal Credit Reports from a recognized credit bureau. Must include
statement that public records have been searched at county, state, and federal levels. Go
to www.myfloridalicense.com/dbpr/pro/elboard/index for a list of acceptable agencies.
(An applicant who is not currently licensed in any local jurisdiction will only be
required to furnish a personal credit report.)
At least two (2) notarized documents on the supplied forms are being provided to
Contractor Certification. These documents reflect my active experience, this
experience totals a minimum of four (4) years within the last eight (8).
The Business and Personal Financial Statement in the application is complete and
notarized. (Financial Statements must be completed in their entirety and must
balance. Financial Statements that contain discrepancies or are incomplete can
lead to denial of an application.) For an applicant not currently duly licensed in any
local jurisdiction, only a personal financial statement will be necessary.
The employment section of application is completed with last five (5) jobs for each of
the years you are qualifying with dates of documented employment.
My correct address, phone number and business name (if applicable) are on the
application.
My letter of reciprocity (if applicable) indicating a minimum grade of 75 percent has
been received by Contractor Certification. The letter must state the name of the exam
that was given by an approved testing firm, the date of the testing and the grade
received.
A copy of my Florida identification and/or Driver's License is attached.
The non-refundable application/background check fee is attached. Contact
Building Division for current fees.
List of last five (5) jobs.
_____(10) Statement of Authority (if applicable).
_____(11) Completed Choice Point Questionnaire (background).
4
If you have any questions regarding this application you may contact us at (352) 754-4050.
FLORIDA STATUTE 837.06 – FALSE OFFICIAL STATEMENTS. Whomever knowingly makes
a false statement in writing with the intent to mislead a public servant in the performance of his or her
official duty shall be guilty of a misdemeanor of the second degree.
I hereby certify that all the information herein contained is true and accurate including all documents
attached. I have read and understand the necessary requirements to obtain a Hernando County
Certificate of Competency. Hernando County Construction Licensing Ordinance, all related building
codes, and Florida State Statutes Chapter 489.
__________________________________ ___________________________________
(Please Print) Applicant's Name Date
__________________________________
Applicants Signature
State of Florida
County of _________________________
The foregoing instrument was acknowledged before me this____day of______________, ________
by_________________________________________________________, who is (___) personally
known to me, or who (___) has produced _________________________________________________
as identification.
______________________________________ ___________________________________
Signature of Notary Notary Stamp
5
ALL INFORMATION MUST BE TYPED OR WRITTEN IN BLACK INK ONLY
Classification Requested:_____________________________________________________________
Mr. / Ms.___________________________________________________________________________
(Last) (First) (Initial)
__________________________________________________________________________________
(Home Address) (City) (State) (County) (Zip Code)
Phone #:(___)_________ _________________________ ____________________________
(Place of Birth) (Date of Birth)
Drivers License No:_________________________________________________________________
__________________________________________________________________________________
FULL NAME OF BUSINESS: Name under which applicant will pull permits
__________________________________________________________________________________
(Business MAILING Address-Street & No.)
__________________________________________________________________________________
(City) (State) (County) (Zip Code)
__________________________________________________________________________________
(Business PHYSICAL Address-Street & No.)
__________________________________________________________________________________
(City) (State) (County) (Zip Code)
Phone #:(____)______________________________Fax # (____)_____________________________
Cell Phone # (____)__________________________E-Mail:__________________________________
6
If qualifying a corporation, a list of all major stock holders will be required on a separate sheet
of paper (all stock holders holding 10% or more of the outstanding stock).
Any applicant applying for the issuance of a certificate to engage in contracting in other
than his individual capacity, such as a partnership, corporation, business trust or other
legal business entity, shall furnish as part of the application a statement that the applicant
is legally qualified to act for the business organization in all matters connected with its
contracting business and that he has authority to supervise construction undertaken by
such business organization.
(1) Any Applicant qualifying to conduct business as a partnership said statement shall be
signed by all partners or, in the event of a limited partnership, by the general partners.
(2) Any applicant qualifying to conduct business as a corporation, said statement shall be
contained in a copy the official minutes of said corporation, certified and attested to by its
secretary.
(3) Any applicant qualifying to conduct business as a business trust, joint venture or any
other legal business entity, such statement shall be signed by the trustees, or by such other
persons as will legally bind said business entity.
Applicant to conduct business as:
( ) INDIVIDUAL ( ) CO-PARTNERSHIP
( ) CORPORATION ( ) SOLE PROPRIETOR
( ) OTHER (specify)____________________________
License No. of any CURRENT OR PREVIOUS Florida Contractor's registration or
Certificate held by applicant in Florida include copies of any other certificates and State
registration if applicable.
______________________ ________________________
County/City License No.
______________________ _________________________
County/City License No.
7
List any other state in which you were licensed previously:
___________________________________________________________________________________
(Name of State) (Type of License Held)
___________________________________________________________________________________
(Town License Held In ) (Phone Number)
___________________________________________________________________________________
(Address) (City) (State) (Zip Code)
If you have taken a Proctored Florida examination for any classification within the past 5
years, enter the class and date below:
______________________ _____________ _____________________ ____________
Classification Date Classification Date
______________________ _____________ _____________________ ______________
Classification Date Classification Date
Schools
Name & Address
Dates
Graduate
High School
College
Voc/Business
Other
8
FINANCIAL INFORMATION REQUIRED
In order that the Building Division may carry out its duty to investigate the financial
responsibility, credit and business reputation (if applicable) of a new applicant for certification, an
applicant shall be required to submit the following information with his or her application for
certification:
(1) Credit reports from any nationally recognized credit bureau dated within four (4) months
of application. The credit reports must be for the applicant and the business entity (if
applicable).
(2) A comprehensive financial statement reflecting the financial condition of the business
entity in its previous fiscal year; provided, however, that the statement be prepared
within twelve (12) months of the date of filing of the application. The financial
statement shall include the following: balance sheet; income statement; capital
statement; and statement of changes in financial position. Unless prepared by a
certified public accountant, the financial statement shall be signed in the presence of
a notary, by a responsible officer of the business entity for the period reflected in the
statement.
Applicants qualifying a business entity shall submit, in addition to the business
financial statement, a personal financial statement. If the applicant has never been
licensed to act in the capacity of a contractor and if the applicant is not qualifying
a business entity, the applicant shall prepare and submit a personal financial
statement in lieu of the business financial statement.
FINANCIAL STATEMENTS FOUND TO BE INCOMPLETE OR INACCURATE MAY BE
DEEMED AS GROUND FOR DENIAL OF APPLICATION.
(3) As a prerequisite to issuance of a certificate, an applicant shall, in addition to the
submissions required in paragraphs (1) and (2) above, submit evidence acceptable to
Contractor Certification demonstrating the following:
(a) Demonstrating the required net worth listed below for the following categories of
contractors.
General, Building, Residential contractors $20,000.00
Sheet Metal, Roofing, Class A, Class B, Mechanical, Commercial Pool/Spa,
Residential Pool/Spa, Plumbing, Underground Utility and Excavation,
Electrical Unlimited, Alarm Systems I and II Solar $10,000.00
Swimming Pool/Spa Service $2,500.00
Specialty Contractors $2,500.00
NET WORTH SHALL BE DEFINED TO REQUIRE A SHOWING FOR ALL
CONTRACTOR CATEGORIES THAT THE APPLICANT HAS A MINIMUM OF
50% OF THE AMOUNT IN CASH. CASH SHALL BE DEFINED TO INCLUDE
A LINE OF CREDIT.
9
(b) Bank statement ( last 3 months) required for cash available.
Proof of Line of Credit.
Possession of either a letter of bondability, a letter of credit or a compliance
bond established to reimburse the appropriate parties for diversion of funds,
abandonment, and all other statutory violations, said instruments to be issued in
the same license classification to dollar ratio listed in paragraph (a), above. The
aforementioned instruments are not to be construed as performance
bonds.
(4) A list of all contracts by the applicant or business organization underway at the time of
filing, if any, along with a list of all contracts completed in the three (3) years
immediately preceding the date of filing, or in the alternative, a list of the five most
recent contracts performed in the applied for category, if any. This list shall include the
description of each job, the dollar value of the job, location, owner, architect and/or
engineer, and general contractor, if applicable.
(5) Letter of financial Responsibility: An original notarized letter from your bank, on bank
letterhead, verifying the applicant's authority to sign checks on the business account or
an original notarized letter from the C.F.O of the business stating the applicant has the
authority to sign checks, payments,drafts, and contracts on behalf of the business.
10
FINANCIAL & LEGAL BACKGROUND
Each person listed in (I) below must answer each question-(Duplicate pages 11 & 12 as needed.)
Name/Title of Person Answering:_________________________________________________
Name of Applicant applying for license:____________________________________________
(a) Has any bonding or surety company ever completed or made a financial
settlement upon any construction contract of work undertaken by any person
named in (I) below or any organization in which any such person was a member
of the personnel? ( )Yes ( )No
If so, attach a detailed statement including: (1) the name and address of the bonding
or surety company, (2) the names and locations of jobs which were completed and
the bonding or surety company made settlement on, (3) the amounts of the
settlements and to whom paid.
(b) Are there now any unpaid, past-due bills or claims for labor, materials, or service
as a result of the construction operations of any person named in (I) below or an
organization in which any such person was a member of the personnel?
( ) Yes ( ) No
If so, attach a detailed statement including the names and addresses of the creditors
and the amounts owed. Any construction obligation shall be deemed to be past due
beyond 90 days following the month in which the purchase was make. Any disputed,
past-due bills must be acknowledged.
(c) Are there now any liens, suits, or judgments of record pending as a result of
construction operations of any person named in ( I ) below or any organization in
which any such person was a member of the personnel as a result of the
construction operation of such person or organization?
( ) Yes ( ) No
If so, attach a detailed statement including the names and addresses of the litigants
in current litigation, the names and addresses of persons who have filed liens or who
have recorded judgments, and the monetary sums involved.
(d) Are there now any liens of record by the U.S. Internal Revenue Service or the
State of Florida Corporate Tax Division against any person named in (I) below or
any organization in which any such person was a member of the personnel?
( ) Yes ( ) No
If so, attach a detailed statement including lien claimants and amounts claimed.
11
(e) Has any person named in (I) below or has any organization in which any such
person was a member of the personnel ever been adjudicated as bankrupt within
the last five years, or is any such person or organization presently in the process
of bankruptcy proceedings?
( ) Yes ( ) No
If so, attach bankruptcy papers.
(f) Has any person named in (I) below or has any organization in which any such
person was a member of the personnel ever made an assignment of assets in
settlement of construction obligations for less than the total amount of the
indebtedness?
( )Yes ( ) No
If so, attach a list of names and addressed of all creditors and losses thus sustained.
(g) Has any person named in (I) below been convicted of acting in the capacity of a
contractor without a license or if licensed as a contractor in this or any other
state, has any disciplinary action (including probation, fine or reprimand) ever
been taken against such license by a state, county, or municipality?
( )Yes ( ) No
If so, attach a detailed statement including the date of conviction or disciplinary
action, whichever may be applicable.
(h) Has any person named in (I) below ever been convicted of a crime, found
guilty, or entered a plea of guilty, or nolo contendere (no contest) to, even if you
received a withhold of adjudication?
( )Yes ( ) No
This question applies to any violation of the laws of any municipality, county, state or
nation, including felony, misdemeanor and traffic offenses (but not parking, speeding,
inspection, or traffic signal violations), without regard to whether you were placed on
probation, had adjudication withheld, were paroled, or pardoned. If you intend to
answer“NO” because you believe those records have been expunged or sealed by court
order pursuant to Section 943.058, Florida Statues, or applicable law of another state, you
are responsible for verifying the expungement or sealing prior to answering “NO”.
YOUR ANSWER TO THIS QUESTION WILL BE CHECKED AGAINST LOCAL,
STATE, AND FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION
ACCURATELY MAY RESULT IN THE DENIAL OF REVOCATION OF YOUR
LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT
WITH AN ATTORNEY OR CONTACT THE DEPARTMENT.
If “YES”, provide a certified copy of disposition for each offense.
Signature of Person Answering:________________________________________________
12
(I) Required signature:
1. If an individual, the applicant
2. If a partnership, the applicant and the partner
3. If a corporation, the president, vice-president and secretary
ALL APPLICATIONS AND FINANCIAL STATEMENTS SUBMITTED FOR PROCESSING
MUST BE TYPED OR WRITTEN IN BLACK INK.
a.____________________________________________ ______________________
Signature of Qualifying Individual Location Address
b.____________________________________________ ________________________
Signature / Title Location Address
c.____________________________________________ ________________________
Signature / Title Location Address
d.____________________________________________ ________________________
Signature / Title
Location
Address
13
FLORIDA STATUTE 837.06 OFFICIAL STATEMENTS. Whomever knowingly makes a false
statement in writing with the intent to mislead a public servant in the performance of his official duty
shall be guilty of a misdemeanor of the second degree.
______________________________________ _________________________________________
APPLICANT – PLEASE PRINT SIGNATURE OF APPLICANT
______________________________________ _________________________________________
NAME OF COMPANY SIGNATURE OF CORPORATE OFFICER
(Other than applicant, if applicant qualifying corporation)
State of Florida
County of______________________________
The foregoing instrument was acknowledged before me this___day of____________,______by
____________________________________who is(__) personally known to me, or who (__) has
produced__________________________________________________as identification.
_____________________________________ ______________________________________
Signature of Notary Commission Number Seal
14
PERSONAL FINANCIAL STATEMENT
(Only for Individuals doing business as Individuals)
Applicant's Name:_____________________________________________________________
ASSETS
DOLLAR VALUE
LIABILITIES
DOLLAR VALUE
Cash Available
$__________________
Mortgage Balance
$___________________
(checking, savings, other)
(1
st
residential)
Provide bank statements
Real Estate Value
$__________________
Mortgage Balance
$___________________
(residence)
(2
nd
residential)
* Real Estate Value
$__________________
Mortgage Balance
$___________________
(other)
(other)
Stocks
$__________________
Note(s) Payable
$___________________
(to banks)
Bonds
$__________________
Note(s) Payable
$___________________
(to others)
Vehicle(s)
$__________________
Vehicle Loan(s)
$___________________
Balance
$__________________
$___________________
Personal Property
$__________________
Personal Loan(s)
$___________________
(furniture, etc.
Balance
Debts Owed to You
$__________________
Other Fixed Debts
$___________________
Owed
Other Property
$__________________
Owned by You
TOTAL ASSETS
$__________________
TOTAL LIABILITIES
$___________________
TOTAL ASSETS
$__________________
TOTAL LIABILITIES (-)
$__________________
NET WORTH
$__________________
15
This financial statement is true and correct to the best of my knowledge
_______________________________________ ___________________________________
Applicant's Signature Print Applicants Name
State of Florida
County of__________________________________
The foregoing instrument was acknowledged before me this____day of_________________,________
by_____________________________________________, who is (__)personally known to me, or who
has produced(__)__________________________________________________as identification.
__________________________________________ ___________________________________
Signature of Notary Public Notary Stamp
16
BUSINESS FINANCIAL STATEMENT
Business Name:______________________________________________________________________
ASSETS
DOLLAR VALUE
LIABILITIES
DOLLAR VALUE
Cash Available
$___________________
Mortgage Balance
$___________________
(checking,savings,other)
(1
st
residential)
Provide bank statements
Real Estate Value
$___________________
Mortgage Balance
$___________________
(residence)
(2
nd
residence)
* Real Estate Value
$___________________
Mortgage Balance
$___________________
(other)
(other)
Stocks
$___________________
Note(s) Payable
$___________________
(to banks)
Bonds
$___________________
Note(s) Payable
$___________________
(to others)
Vehicle(s)
$___________________
Vehicle Loan(s)
$___________________
Balance
$___________________
$___________________
Personal Property
$___________________
Personal Loan(s)
$___________________
(furniture,etc.)
Balance
Debts Owed to You
$___________________
Other Fixed Debts
$___________________
Owed
Other Property
$___________________
Owned by You
TOTAL ASSETS
$___________________
TOTAL LIABILITIES
$___________________
TOTAL ASSETS
$_______________
TOTAL LIABILITIES (-)
$_______________
NET WORTH
$___________________
17
This financial state is true and correct to the best of my knowledge.
____________________________________________
Applicant's Signature
State of Florida
County of_____________________________________
The foregoing instrument was acknowledged before me this___day of______________,_________,by
________________________________________________________, who is (__)personally known to
me, or who(__) has produced___________________________________________________________
as identification.
________________________________________ ___________________________________
Signature of Notary Public Notary Stamp
18
STATEMENT OF AUTHORITY TO ACT FOR THE BUSINESS ORGANIZATION
Statement of Authority
In making application to qualify a company, corporation, partnership, limited partnership, individual,
or any other type of business entity, I understand that I, as qualifying agent, am completely
responsible for the actions of said business entity as they relate to its construction business.
Further, I understand that the Hernando County Building Division holds the qualifying agent
responsible for supervision of job sites a well as financial aspects of the entity's construction
business including, but not limited to, payment to subcontractors, payment to suppliers, payment to
employees and payment of applicable federal and state taxes.
I understand that the Hernando County Building Division holds me, as qualifying agent,
responsible for any violation which may be committed by the business entity I qualify.
Required Signature: 1) If an individual, the applicant
2) If a partnership, the applicant and the partner
3) If a corporation, the applicant and the officers of the corporation
APPLICANTS SIGNATURE: ______________________________________________
PARTNER/CORPORATE OFFICERS: ______________________________________________
______________________________________________
______________________________________________
STATE OF FLORIDA
COUNTY OF__________________________
The foregoing instrument was acknowledge before me this ___day of____________,________,by
_______________________________________________, who is (__) personally known to me,or who
(__) has produced_______________________________________________________as identification.
__________________________________________ ___________________________________
Signature of Notary Public Notary Stamp
19
NOTICE REGARDING CORPORATIONS
Upon the advice of the Attorney General, it is the policy of this agency not to issue a certificate of
competency to a qualifying agent of a corporation unless it is qualified to do business in this State
either as a domestic or a foreign corporation. To be qualified to do business in this State, a domestic or
foreign corporation must be registered and in good standing with the Secretary of State of the State of
Florida.
COMPLETE THE CERTIFICATE BELOW AND SUBMIT IT WITH YOUR
APPLICATION
__________________________________________________________________________________________
CERTIFICATE OF INCORPORATION
(Attach a Copy of Certificate of Incorporation Issued by Secretary of State of Florida)
On this___day of_____________, ____, in __________________________, I certify under
penalty of perjury that____________________________, being a domestic corporation with its
main office in the County of___________________,or a foreign corporation incorporated in the
State of_________________(if applicable) on_______________,______, was registered with
the Secretary of the State of Florida on the_____day______________,_____; that the number
assigned to this corporation is____________________________;that the name style as set forth
on the application for this corporation is the same as that registered with the Secretary of State.
The Construction Industry Licensing Law Provides:
468.107(2) If the applicant is proposing to qualify a partnership, corporation, business trust, or
other legality, the application shall state the name of the partnership and of its partners, or the
name of the corporation and of its officers and directors, or the name of the business trust and
its trustees, or the name of such other legal entity and its members, and furnish evidence of
statutory compliance if a fictitious name is used.
Such application shall also show that the person applying for the examination is legally
qualified to act for the business organization in all matters connected with its contracting
business; and that he has authority to supervise construction undertaken by such business
organization. The certification, when issued upon application of a business organization, shall
be in the name of the qualifying agent and the name of the business organization shall be
noted thereon.
At least one member or supervising employee of the business organization shall be duly
licensed in Hernando County in order for the business to be qualified locally to engage in the
category of the business for which the member or supervising employee is licensed. If any
individual so qualified on behalf of such business organization ceases to be affiliated with such
business organization, he shall inform the board's principle office as provided in Hernando
County Licensing Ordinance. In addition, if such individual is the only qualified individual
affiliated with the business organization, the business organization shall notify the board's
principal office of the individual's termination and shall have a minimum of 60 days from the
termination of the individual's affiliation with the business organization in which to obtain
another qualifying person under the provisions of this part. The business organization shall not
be authorized to contract until a qualifying individual is obtained.
The individual shall also inform the boards principle office in writing when he proposes to
engage in contracting in his own name or in affiliation with another business organization; and
he or such new business organization shall supply the same information to the board as required
for applicants under this part.
20
REQUIRED INFORMATION CONCERNING BUSINESS ORGANIZATIONS
(Please attach a copy of your compliance with the Fictitious Name Law when applicable)
Fictitious Name Law 865.09 Statute, in Part:
It shall be unlawful for any person or persons, as defined herein, to engage in business under a fictitious
name unless said fictitious name shall be registered with The Florida Department of State Division of
Corporation. An application for registration may be obtained by contacting the division of Corporation:
Fictitious Name Registration
Post Office Box 1300
Tallahassee, Florida 32302-1300
Phone Number (850) 488-9000
A person may not act in a qualifying capacity on behalf of more than one firm except under certain
specific conditions.
1. Is the person who is to qualify_____________________________legally qualified to act for the
business organization in all matters connected with its contracting business? ( )Yes ( ) No
2. Is the person who is to qualify the business organization mentioned above, presently qualifying
or attempting to qualify another business organization? ( ) Yes ( ) No
If so, give name of the business organization(s) that is qualified or is to be qualified by the
applicant._____________________________________________________________________
3. Will there be any ownership by the applicant of the business organization named in question 1
above: (If so, give details by attachment.) ( ) Yes ( ) No
4. Will there be any ownership by the applicant of the business organization named in question 2
above: (If so, give details by attachment.) ( ) Yes ( ) No
5. Is the business organization a subsidiary of, or a joint venture with, any firm named in answer to
question 2 above? ( If so, give details by attachment.) ( ) Yes ( ) No
6. If qualifying a corporation, a list of all major stock holders will be required on a separate sheet
of paper. (10% or more of outstanding stock).
21
FLORIDA STATUTE 837.06 – FALSE OFFICIAL STATEMENTS. Whomever knowingly makes
a false statement in writing with the intent to mislead a public servant in the performance of his official
duty shall be guilty of a misdemeanor of the second degree.
We certify that all information herein contained is true and accurate including all statements attached.
Signed_____________________________________ Title________________________________
Person Authorized to Sign
Signed_____________________________________ Title________________________________
Individual Qualifying Organization
State of Florida
County of ___________________________________
The foregoing instrument was acknowledged before me this____day of _______________,_______, by
____________________________________________ who is (__) personally known to me, or who
has produced___________________________________________________________as identification.
________________________________________ _________________________________________
Signature of Notary Public Notary Stamp
22
EXPERIENCE RECORD (duplicate as necessary)
NOTE: START WITH MOST RECENT EMPLOYMENT FOR THE PAST 5 YEARS.
Employer:_____________________________________Phone_________________________
Address:_________________________City:___________________________State__________
Employment Dates: From_______________________ To _____________________________
Position of Applicant:___________________________________________________________
Description of Duties:___________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------
Employer:______________________________________Phone________________________
Address:___________________________City:__________________________State_________
Employment Dates: From_______________________To______________________________
Position of Applicant:___________________________________________________________
Description of Duties:___________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------
Employer:_______________________________________Phone_______________________
Address:____________________________City:__________________________State________
Employment Dates: From_______________________To______________________________
Position of Applicant:___________________________________________________________
Description of Duties: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
23
DOCUMENT OF EXPERIENCE
Certification Requested:_____________________________ Date:_____________________________
Applicant's Name: ___________________________________________________________________
Person Documenting Experience:________________________________________________________
Company Name:_____________________________________________________________________
Address:___________________________________________________________________________
City:_________________________________________State:____________Zip:_________________
Phone Number: (___) ___________________ (___) ______________________________
Business Home
License Number:____________________________________________________________________
Length of time known: From_______________ To_______________
Tell in your own words what you know of the applicant's experience. Describe the type of work he/she
performed and his/her position as apprentice, helper, journeyman, foreman, supervisory employee, or
contractor. Describe the kind of building, structures or projects worked upon. Give any other details
that might aid in evaluating his/her experience.
24
_________________________________________ _________________________________________
Print Name Signature
State of Florida
County of_____________________
Subscribed and sworn to me this ______day of ____________________,____________by
_____________________________________who(___)is personally known to me, or who has
produced________________________________________________as identification.
____________________________________
Signature of Notary
________________________________
Notary Stamp
Mail To: Hernando County Building Division
789 Providence Blvd.
Brooksville, FL 34601
25
DOCUMENT OF EXPERIENCE
Certification Requested:_____________________________ Date:_____________________________
Applicant's Name: ___________________________________________________________________
Person Documenting Experience:________________________________________________________
Company Name:_____________________________________________________________________
Address:___________________________________________________________________________
City:_________________________________________State:____________Zip:_________________
Phone Number: (___) ___________________ (___) ______________________________
Business Home
License Number:____________________________________________________________________
Length of time known: From_______________ To_______________
Tell in your own words what you know of the applicant's experience. Describe the type of work he/she
performed and his/her position as apprentice, helper, journeyman, foreman, supervisory employee, or
contractor. Describe the kind of building, structures or projects worked upon. Give any other details
that might aid in evaluating his/her experience.
___________________________________________________________________________________
26
_________________________________________ _________________________________________
Print Name Signature
State of Florida
County of_____________________
Subscribed and sworn to me this ______day of ____________________,____________by
_____________________________________who(___)is personally known to me, or who has
produced________________________________________________as identification.
____________________________________
Signature of Notary
________________________________
Notary Stamp
Mail To: Hernando County Building Division
789 Providence Blvd.
Brooksville, FL 34601
27
Applicant Job List (Duplicate as necessary)
List five jobs for each of the years you are qualifying (e.g. 3 yrs management, 4yrs. supervisory, or
4 yrs trade, with dates that concur with documented employment.
1. Contractor name____________________________________Phone #____________________
Job Location Address__________________________________________________________
Approximate Value of Job $__________________
Type of work ( commercial or residential )__________________________________________
2. Contractor Name______________________________________________________________
Job Location Address___________________________________________________________
Approximate Value of Job $__________________
Type of work (commercial or residential)___________________________________________
3. Contractor Name_______________________________________Phone #_________________
Job Location Address___________________________________________________________
Approximate Value of Job $__________________
Type of work (commercial or residential)___________________________________________
4. Contractor Name_______________________________________Phone #_________________
Job Location Address__________________________________________________________
Approximate Value of Job $__________________
Type of work (commercial or residential)___________________________________________
5. Contractor Name_______________________________________Phone #_________________
Job Location Address __________________________________________________________
Approximate Value of Job $__________________
Type of work (commercial or residential)___________________________________________
Class app 9/15 28
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CONTRACTOR CLASS CERTIFICATION APPLICATION (HERNANDO COUNTY BUILDING DIVISION)

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Completed 2 September 2020

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