Fillable Contractor Registration Application And Bond Form (City of Grove City)

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Contractor Registration Application And Bond Form (City of Grove City)

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BROWSE CITY OF GROVE CITY (OH) FORMS

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Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
OFFICE USE
Receipt # ______________
Ref. # __________________
Date Entered ____________________
Approved _______ Date ___________
ALL REGISTRATIONS (with the exception of General Contractor) MUST PROVIDE ONE OF THE FOLLOWING:
o Columbus License o State of Ohio License o Passing score on Grove City-Approved Test
REGISTRATION TYPE q New Registration q Renewal
o General Contractor
General contractors can pull only the following permits:
RESIDENTIAL — new houses • COMMERCIAL — new buildings, remodels
o Concrete Forming and Placing & Finishing
o General Sign Contractor
o Medical Gas
o Swimming Pool
o Sewer Contractor
o Demolition
o Water Tapper
No registration fee, insurance or bond is required for water tapper
but a current City of Columbus license and RITA tax form is required.
OHIO CONSTRUCTION INDUSTRY LICENSING BOARD (OCILB) REGISTRATION
Must include a copy of your current State of Ohio License, along with all other documentation listed below.
o Electric o HVAC o Plumbing o Hydronics o Refrigeration
FIRE REGISTRATION
Must include a copy of your current State of Ohio License, along with all other documentation listed below.
oAutomatic Sprinkler & Standpipe Systems o Fire Service Mains o Fire Pumps
o Engineered Extinguishing Equipment (OTW) o Household Fire Warning Equipment Only
o Fire Alarm & Detection Equipment o Pre-Engineered Extinguishing Equipment (OTW)
CONTRACTOR REGISTRATION
APPLICATION
$100 Per Registration Type. Check each box that applies.
THIS REGISTRATION IS REVOCABLE OR MAY BE SUSPENDED IF THE TERMS AND CONDITIONS UNDER WHICH IT IS GRANTED ARE VIOLATED.
IT IS THE RESPONSIBILITY OF THE CONTRACTOR TO ENSURE LIABILITY INSURANCE, BOND AND STATE LICENSE(S) ARE UPDATED AND REMAIN
VALID TO PREVENT DELAYS IN PROCESSING PERMITS AND INSPECTIONS. WORK SHALL NOT BE STARTED WITHOUT AN APPROVED PERMIT.
SUBMITTAL REQUIREMENTS
NOTE: Insurance, state and city license documentation must be provided before any registration
is processed. No copies will be retained from previous years.
CERTIFICATE OF INSURANCE ($300,000 min. liability)
Certificate holder must be Grove City
Insurance Company: ________________________
Representative: ___________________________
Phone: _________________ Expiration: ________
$15,000 Bond (Signed & Sealed)
Continuation certificates accepted if original bond
is on file with Grove City Building Division.
Bond Company:
___________________________
Representative: ____________________________
Surety Bond Amount: $15,000 required
Expiration: _________ Bond No.:
______________
STATE LICENSE (for OCILB and Fire Contractors)
License No: ______________ Expiration:
_____
License Type: __________________________
CITY OF COLUMBUS LICENSE
(OCILB and Fire Contractors are exempt)
License No: ______________ Expiration: _____
License Type: __________________________
• Test score (if required) from Grove City-approved
testing facility:
________________________
• RITA Form 48 (City Tax) - See attached form
HOME IMPROVEMENT AND LIMITED
CONTRACTOR REGISTRATION
o Home Improvement General Contractor
RESIDENTIAL:
o Roofing
o Siding, Windows and Doors
o Wood Deck Installation
o Basement Waterproofing
o Masonry Fireplaces
o Sidewalks and Driveway Approaches
o Fencing
Page 1 of 6
Business Name ________________________________________________ Expiration Date:_______________ Registration No.____________________
FEES
$100 Per Registration Type.
Quantity of Registrations
_________
Multiplied by
$100
Total Fees Due
$ _________
CONTRACTOR INFORMATION Company Name _________________________________________________________
License Holder
_____________________________________________ Website Address ________________________________________
Address
_____________________________________________________________________________________________________________
City/State/Zip______________________________________________
Phone________________________Cell_________________________
Email _____________________________________________________
Federal I.D./SSN ___________________________________________
@ _____________________________________
@ _______________________________________
@ _______________________________________
@ _______________________________________
Revised 6/2020
o Cash
o Card
o Check
Social
Media
Account
Handles
Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
CONTRACTOR INFORMATION
Name _____________________________________________________________________ Date of Birth ______________________________
Dates of any previous registrations with Grove City Building Division _________________________________________________________
Is the applicant 18 years of age or older? o Yes o No Is the applicant a United States citizen? o Yes o No
Has the applicant been convicted of a felony?
o Yes o No If yes, explain __________________________________________________
________________________________________________________________________________________________________________________
Does the applicant have a record of code violations?
o Yes o No If yes, explain ____________________________________________
________________________________________________________________________________________________________________________
Has the applicant been sanctioned by any body for dishonest practice or malpractice?
o Yes o No If yes, explain ______________
________________________________________________________________________________________________________________________
ACKNOWLEDGEMENT OF CONTRACTOR
REGISTRATION MINIMUM REQUIREMENTS
BUSINESS
Address
______________________________________________
City/State/Zip __________________________________________
Phone ________________________________________________
RESIDENCE
Address
______________________________________________
City/State/Zip __________________________________________
Phone ________________________________________________
EXPERIENCE/EDUCATION/TESTING
All first-time registrations that don’t include a state and/or Columbus license must include records of all available testing results as
well as a statement of experience that includes all of the following items:
• List of employment or projects with dates of same
• Detailed work-related information about the employment or projects listed
• Length of time devoted to each such employment or project listed
• Name of the employer or other responsible person with direct knowledge of the quality of the work performed by the applicant
• Statement about the applicant’s character by each such employer or responsible project manager
• Statement by the applicant of all schooling and training obtained by the applicant
Contractor Registration Application - Page 2 of 6
NOTARIZED SIGNATURE
I, _____________________________ attest that I meet the minimum experience requirements for contractor registration in the City of
Grove City and that the information contained within this application an all attached documents is true and complete.
Signature of applicant ___________________________________________________________ Date
__________________________________
Sworn to before me and subscribed in my presence this ______________ day of ________________________, in the year ____________.
Notary Public
_________________________________________________________ My commission expires ___________________________
NOTARY SEAL HERE
Falsification of a public document is a violation of the Ohio Revised Code, section 2921.13(a)(3), a misdemeanor of the first degree,
punishable by up to six months imprisonment and a fine of one thousand dollars ($1,000.00) or both.
Revised 4/2019
Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
ACKNOWLEDGEMENT OF CONTRACTOR
REGISTRATION MINIMUM REQUIREMENTS
MINIMUM EXPERIENCE REQUIREMENTS BY CONTRACTOR TYPE
HOME IMPROVEMENT GENERAL CONTRACTOR
Applicant shall have a minimum of three full years experience
in the home improvement field.
HOME IMPROVEMENT LIMITED CONTRACTOR
Applicant shall have a minimum of one full year of experience
in the field for which the applicant is registering:
• Residential roofing
• Residential siding, windows and doors
• Residential wood deck installation
• Residential basement waterproofing
• Residential masonry fireplaces
• Residential fencing
• Residential sidewalks and driveway approaches
• Residential pools and spas
SEWER CONTRACTOR
The minimum experience required for an applicant shall be
evidenced in writing and shall have been obtained in any of
the following ways:
• Two consecutive full years of experience under the
supervision of a City or other recognized jurisdiction’s
registered sewer contractor
• Three cumulative, nonconsecutive, full years of experience
under the supervision of a City or other recognized
jurisdiction’s registered sewer contractor
• A current, valid registration as a sewer contractor in another
recognized city, county or state
• Two full years of experience working on sewer systems
GENERAL SIGN CONTRACTOR
The minimum experience required for an applicant shall be
evidenced in writing and shall have been obtained in any of
the following ways:
• Two consecutive, full years of experience under the
supervision of a City or other recognized jurisdiction’s
registered general sign contractor
• Three cumulative, nonconsecutive, full years of experience
under the supervision of a City or other recognized
jurisdiction’s registered general sign contractor
• A current, valid registration as a general sign contractor in
another recognized city, county or state
• Two full years of experience working on sign systems
DETERMINATION OF A FULL YEAR
A “full year” of experience, as required above, shall be based on 12 consecutive calendar months during which the applicant shall
have been gainfully and verifiably employed for not less than 1,600 working hours at the specific craft, trade or profession for which
an application for a Grove City Building Division-issued registration has been made.
Contractor Registration Application - Page 3 of 6
Revised 4/2019
Grove City Building Division
4035 Broadway
Grove City, OH 43123
614-277-3075 (Phone)
614-277-3090 (Fax)
GroveCityOhio.gov
CONTRACTOR REGISTRATION
BOND FORM
Bond No. ___________________________________________ Date _____________________________ Amount $15,000
KNOW ALL MEN BY THESE PRESENTS:
That (Licensee/Certificate Holder)
________________________________________________________________________________________
of (Company Name) ____________________________________________________________________________________________________
as Principal and (Bond Company) ________________________________________________________________________________________
as Surety, are held firmly bound unto the City of Grove City, Grove City c/o City Treasurer for the General Fund, City of Grove City,
4035 Broadway Grove City, OH 43123, as Obligee, in the sum of Fifteen Thousand and no/100th Dollars ($15,000.00) to be paid to
said Obligee City, its successors and assigns, and for the payment thereof well and truly to be made, we, Principal and Surety, jointly
and severally bind ourselves, our heirs, executors, administrators, successors, and assigns firmly by these presents. The conditions of
the above obligation are such that:
WHEREAS, the above principal has or is about to apply to said Obligee for a license/registration as a, (all registration types must be
listed)
_____________________________________________________________________________________________________________ Contractor
for the term commencing this date and ending (MO/DAY/YR) ____________________________, pursuant to GROVE CITY CODIFIED
ORDINANCES, Chapter 1377.06, 1377.04 & 1375.06, May 16, 2002 as applicable.
WHEREAS, Principal, his agents and employees shall save the City harmless from all loss and damage to persons or property which
may be occasioned in any way, by accident or the want of care or skill on applicant’s part, in the prosecution of the work contracted,
performed, pursued or attempted under such license/registration.
NOW THEREFORE, if the license/registration shall be issued to Principal, his agents and employees shall save the City harmless from
all loss and damage to persons or property of the City and aforesaid, then this obligation shall be void; otherwise, the same shall
remain in full force and effect.
IT IS FURTHER AGREED AND UNDERSTOOD that the Surety Company reserves the right to cancel this bond by giving 30 days
written notice to Obligee c/o Administrator for The Building Division, Grove City, OH 43123, upon receipt of such cancellation notice,
Surety Company is relieved of any further liability. The Surety Company will be liable for loss accruing up to the effective date of said
cancellation notice, but in no event to exceed said $15,000.00
Signed this ______________ day of __________________________________________________, in the year
___________________________
Licensee/Certificate Holder____________________________________________By _______________________________________________
Print or Type Name Must be signed (Signature)
Surety _____________________________________________ By (Attorney-in-fact)
________________________________________________
Print or Type Name Signature
SEAL
Contractor Registration Application - Page 4 of 6
Revised 4/2019
www.ritaohio.com
BUSINESS REGISTRATION FORM 48
MUNICIPALITY
FEDERAL IDENTIFICATION NUMBER SOCIAL SECURITY NUMBER (COMPLETE ONLY IF A SOLE PROPRIETOR)
FILING STATUS:
RITA LOCATION NAME AND ADDRESS AS USED FOR BUSINESS PURPOSES
BUSINESS NAME:
PHONE: ( )
ADDRESS: CITY: STATE: ZIP:
IF CORPORATE SUBSIDIARY, GIVE NAME AND ADDRESS OF PARENT COMPANY MAIN OFFICE
BUSINESS NAME:
ADDRESS: CITY: STATE: ZIP:
IF SOLE PROPRIETORSHIP, GIVE OWNER’S NAME AND HOME ADDRESS
NAME:
PHONE: ( )
ADDRESS: CITY: STATE: ZIP:
WHAT DATE DID YOU BEGIN OPERATIONS IN A RITA MUNICIPALITY?
NAICS
PLEASE LIST THE COMPANY NAICS CODE OR CHECK THE BOX THAT BEST DESCRIBES THE COMPANY BUSINESS TYPE
TRANSPORTATION NON MANUFACTURING MANUFACTURING WHOLESALE
RETAIL
FINANCE SERVICES
PUBLIC ADMINISTRATION
NON CLASSIFICATION
DO YOU HAVE ANY EMPLOYEES? (CHECK ONLY ONE)
YES
NO
ARE CONTRACTORS UTILIZED? (CHECK ONLY ONE)
*IF YES COMPLETE REVERSE SIDE.
YES*
NO
EMPLOYEE INFORMATION
IF YOU HAVE EMPLOYEES PROCEED WITH EMPLOYEE INFORMATION. IF YOU DO NOT HAVE EMPLOYEES PROCEED TO THE PROFIT/LOSS SECTION.
NUMBER OF EMPLOYEES AT RITA LOCATION: MONTHLY GROSS PAYROLL AT RITA LOCATION:
WILL YOU BE WITHHOLDING RESIDENCE TAX ONLY?
YES
NO
SEND WITHHOLDING TAX FORMS TO
BUSINESS NAME:
PHONE: ( )
CARE OF:
ADDRESS: CITY: STATE: ZIP:
SEND NET PROFIT TAX RETURN TO
BUSINESS NAME:
PHONE: ( )
CARE OF:
ADDRESS: CITY: STATE: ZIP:
IF YOU ARE A NON-PROFIT ORGANIZATION STOP HERE AND SIGN AT BOTTOM
PROFIT/LOSS INFORMATION
ENDING DAY OF FISCAL YEAR IF OTHER THAN CALENDAR YEAR
/
MONTH
/
DAY YEAR
THE INFORMATION HEREBY SUBMITTED IS TRUE AND CORRECT.
SIGNATURE:
DATE:
PRINT NAME:
TITLE: PHONE:
REGIONAL INCOME TAX AGENCY
ATTN: BUSINESS REGISTRATION
P.O. BOX 477900 BROADVIEW HEIGHTS, OH 44147-7900
CLEVELAND TOLL FREE:
(800) 860-RITA (7482)
COLUMBUS TOLL FREE: (866) 721-RITA (7482)
TDD: (440) 526-5332
YOUNGSTOWN TOLL FREE: (866) 750-RITA (7482)
FAX: (440) 526-3136
CORPORATION
PARTNERSHIP
SOLE PROPRIETOR
NON-PROFIT
S-CORP.ESTATE/TRUST LLC
Page 5 of 6Contractor Registration Application -
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CONTRACTOR INFORMATION
MUNICIPALITY:
ADDRESS OF CONSTRUCTION SITE:
BUILDING PERMIT #:
TOTAL CONTRACT AMOUNT: $
As the contractor, will your company be withholding local income tax from all
employees on the job?
YES
NO
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COMPANY/ADDRESS - CITY, STATE AND ZIP
OFFICER/OWNER NAME
PHONE NUMBER
SOCIAL SECURITY OR
FEDERAL I.D. NUMBER
ESTIMATED
WAGES PER MONTH
ESTIMATED
START DATE
NUMBER OF
EMPLOYEES
TRADE
If necessary attach a separate sheet
The information requested on this form is essential to the establishment of your account and will be held
in strict confidence. Please complete and sign this Registration Form and return within 15 days. Prompt
completion of this form now can save you the expenditure of additional time and effort in the future. If you
have any questions please contact the Business Registration Department at one of the numbers below.
Thank you for your cooperation.
SEND RESPONSE TO:
REGIONAL INCOME TAX AGENCY
ATTN: BUSINESS REGISTRATION
P.O. BOX 477900
BROADVIEW HEIGHTS, OH 44147-7900
CLEVELAND TOLL FREE: (800) 860-RITA (7482) TDD: (440) 526-5332
COLUMBUS TOLL FREE: (866) 721-RITA (7482) FAX: (440) 526-3136
YOUNGSTOWN TOLL FREE: (866) 750-RITA (7482)
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Page 6 of 6Contractor Registration Application -
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Contractor Registration Application And Bond Form (City of Grove City)

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Completed 18 July 2020

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