CONTRACTOR REGISTRATION FORM
CITY OF MIDLAND BUILDING DEPARTMENT
333 W. ELLSWORTH ST., MIDLAND, MI 48640
989-837-3383
THE FOLLOWING INFORMATION IS REQUIRED BY PUBLIC ACT 230 OF 1972 FOR ALL
PERMIT APPLICATIONS FOR WORK ON RESIDENTIAL BUILDINGS OR STRUCTURES. THE
CITY OF MIDLAND ALSO REQUIRES A COPY OF YOUR CURRENT CONTRACTORS
LICENSE AND A $15 ADMINISTRATIVE FEE (PAYABLE TO THE CITY OF MIDLAND) FOR
REGISTRATION.
COMPANY NAME _______________________________________________________
ADDRESS _______________________________________________________
_______________________________________________________
PHONE # _______________________________________________________
EMAIL ADDRESS _______________________________________________________
STATE LICENSE # _________________________ EXP. DATE _______________
FEDERAL EMP ID # _________________________
REASON FOR EXEMPTION FROM SECTION 6109 OF IRS CODE:
_______________________________________________________________________
MESC EMP # _________________________
REASON FOR EXEMPTION FROM MRSC ACT 1936 (ExSess) PA1, MCL 421.1 TO 421.75:
_______________________________________________________________________
INSURANCE CARRIER _____________________________________________________
REASON FOR EXEMPTION FROM WORKERS DISABILITY ACT OF 1969, 1969 A 317 MCL418.101 TO
418.941:
_______________________________________________________________________
A COPY OF YOUR CURRENT CONTRACTORS LICENSE AND A
$15 ADMINISTRATION FEE MUST BE INCLUDED.
Rev 4/30/13
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