Fillable Engineering Mechanical Electrical Plumbing Specialty Plumbing and Liquefied (Broward County)

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Engineering Mechanical Electrical Plumbing Specialty Plumbing and Liquefied (Broward County)

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Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION
1 North University Drive, Box #302 • Plantation, Florida 33324 • 954-765-4400 • broward.org/building/contractors
Engineering
Mechanical
Electrical
Plumbing
Specialty Plumbing and
Liquefied Petroleum Gas (LPG) Trades Contractor
Certificate of Competency Application Information and Instructions
You must submit your application package in the following order:
1) Fully completed application, 2) Affidavits, 3) Credit references, 4) Credit report, 5) Corporate documents
IN ORDER TO APPLY, YOU MUST HAVE THE FOLLOWING PRACTICAL CONSTRUCTION EXPERIENCE:
Electrical and Specialty Electrical Contractor
7 years
Engineered Construction Contractor
10 years
Specialty Engineered Trades
Underground Utility and Excavation
6 years
Secondary Utility and Excavation
4 years
Jack and Bore Installer
4 years
Pipeline Rehabilitation
4 years
Directional Drilling
4 years
Pipe Bursting
4 years
Plant Construction
6 years
Fuel Transmission and Distribution Lines
6 years
Underground and Aerial Utility Transmission and Distribution Lines
4 years
Feeder Distribution Interface (FDI Telephone Boxes) Installer
3 years
Cable Television (for pre-wiring buildings, apply with Electrical Board)
3 years
Heavy Marine
6 years
Bridges, Overpasses, Underpasses
4 years
Light Marine
4 years
Pile Driving
4 years
Major Roads
6 years
Minor Roads
4 years
Concrete Driveways, Curbs, Gutters, Driveway Entrances and Sidewalks
4 years
Sealcoating
1 year
Striping, Marking and Signage of Roadways (including pavements)
3 years
Excavating
4 years
Clearing and Grading
3 years
Dredging
3 years
Liquefied Petroleum Gas Contractor
Reciprocity only
Plumbing and Specialty Plumbing Contractors
Master Plumber
7 years
Irrigation Specialty Contractor
4 years
Mechanical and Specialty Mechanical Contractors
Mechanical Contractor
6 years
Class A Air Conditioning
6 years
Sheet Metal
6 years
Insulation
3 years
Test and Balance – Class A Unlimited
*
*Must have held a Class A Air Conditioning license for 3 years and have AABC or NEEB certification
4 years
Central Vac System
3 years
Pneumatic Control
3 years
Class B Air Conditioning
*
*Limited to 25 tons
3 years
Test and Balance – Class B Limited
*
*Limited to 25 tons; must have held a Class B Air Conditioning license for 3 years and have AABC or NEEB certification
3 years
Transport Assembly
3 years
2
Proof of Experience
Submit the affidavit provided on page 10 or provide a letter (on business letterhead) from your employer, including:
Dates you were employed
Type of work you performed
License number of the person signing the documents (must be notarized)
W2 forms to substantiate each affidavit
If you are self-employed, you must include:
Copies of your incorporation papers
Copies of your occupational license(s)
Copies of any license(s) you may have had
Any other documents to support your status as self-employed
If you have out-of-state experience, you must include:
A notarized letter from a licensed architect or engineer from that state*
*
does not apply to electrical and plumbing
If you are applying for reciprocity, you must include:
A letter of reciprocity from the county where you took your exam; the letter must arrive via
the mail or be submitted with a seal. The scope of work must be equal to Broward
County’s requirements.
You may receive a “Notice to Appear” at an upcoming scheduled Board meeting.
All letters and affidavits must be notarized
Character Letters
Please provide the name and address of at least one local resident who can attest to your character and
reputation. Letter(s) must be notarized
Credit References
Please provide three credit references; at least one reference must be from a local financial institution, such as a
bank.
Personal Credit Report
Please provide an individual credit report, no more than six months old. The report must come from a nationally
recognized credit bureau.
Business Credit Report
If you are qualifying a corporation or partnership, a company credit report is also required.
Corporate Financial Statement
If you already have an active corporation, please provide a comprehensive financial statement, notarized by your
accountant. The statement should be no more than 180 days old. If over 90 days old, it needs to be accompanied
by a notarized affidavit stating that no material change has occurred since its preparation and that it substantially
represents your current financial condition and the business organization.
Corporate Papers
If you are qualifying a corporation, you are required to provide:
A copy of the front page of your articles of incorporation, listing the corporate officers
A written statement from the Secretary of State, Tallahassee, certifying the corporation is currently
authorized to do business in the State of Florida
3
If you are not an officer of the corporation, you must provide a notarized letter from an officer of the
corporation stating that you are a supervisory employee of the corporation.
Fictitious Corporate Name
If the firm is not incorporated but is operating under a trade name – other than your proper name – the company
must conform to Florida Statute §865.09 and must be properly registered with the Florida Division of
Corporations.
Certificates of Insurance
After you have passed your exam, you will be required to submit certificates of insurance. Reciprocity applicants
will be required to submit insurance at the time of application. The minimum liability insurance amounts are:
Bodily Injury ............................... $300,000
Property Damage* ..................... $50,000
*for any one accident, including damage to rights-of-way and/or shrubbery
Worker’s Compensation Insurance
In addition to the certificates of insurance listed above, you will need to submit proof of worker’s compensation
insurance or a waiver stating exemption from Florida’s Workers Compensation law.
Each certificate must list as a certificate holder:
Broward County Building Code Services Division
1 North University Drive, Mailbox 302
Plantation, Florida 33324
All Certificates must provide at least 30 days advance notice of cancellation
Photographs
You must include two passport-sized photos of yourself taken within the last three months and also a clear copy
of a valid driver’s license or other government issued ID.
Processing Fees
Electrical & Specialty Electrical Contractors ............................ $300
Engineered Construction Contractors ..................................... $430
Specialty Engineered Construction Contractors ...................... $315
Liquefied Petroleum Gas (LPG) Contractors ............................ $200
Plumbing & Specialty Plumbing Contractors ........................... $250
Mechanical & Specialty Mechanical Contractors .................... $275
Please make checks payable to: Broward County Board of County Commissioners
All fees are non-refundable
Notification
After the Board reviews your application, you will be advised of their decision by letter.
Testing
Once approved, your contact information will be sent to Gainesville Independent Testing Service, LLC (GITS).
They will contact you to schedule your exams.
Applicants are required to pass with a minimum passing score of 75% (also applies to reciprocity applicants)
Answer all questions in full, please type or print clearly with sufficient detail to determine if you are qualified to
take the examination. If not applicable indicate N/A. Attach additional sheets if necessary.
4
Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION
1 North University Drive, Box #302 • Plantation, Florida 33324 • 954-765-4400 • broward.org/building/contractors
Engineering
Mechanical
Electrical
Plumbing
Specialty Plumbing and
Liquefied Petroleum Gas (LPG) Trades Contractor
Application for Certificate of Competency
New License License by Reciprocity
Contractor Classification
ELECTRICAL & SPECIALTY ELECTRICAL CONTRACTORS
Alarm System Contractor I
Limited Energy Systems Contractor
Alarm System Contractor II
Master Electrician
ENGINEERED CONSTRUCTION CONTRACTOR
General Engineered Construction Builder
SPECIALTY ENGINEERED CONSTRUCTION CONTRACTOR
Category 1A: Specialty Engineered Utility System
1A-A Underground Utility and Excavation
1A-B Secondary Utility and Excavation
1A-C Jack and Bore Installer
1A-D Pipeline Rehabilitation
1A-E
Directional Drilling
1A-F
Pipe Bursting
Category 1B: Specialty Engineered Structural
1B Plant Construction
Category 1C: Engineered Specialty Transmission and Distribution
1C-A Fuel Transmission and Distribution Lines
1C-B Underground and Aerial Utility Transmission and Distribution Lines
1C-C Feeder Distribution Interface (FDI Telephone Boxes) Installer
1C-D Cable Television (for pre-wiring buildings apply with Electrical Board)
Category 2: Specialty Engineered Structural
2A Heavy Marine
2B Bridges, Overpasses, Underpasses
2C
Light Marine
2D
Pile Driving
Category 3: Specialty Engineered Roads and Surfacing
3A Major Roads
3B Minor Roads
3C Concrete Driveways, Curbs, Gutters, Driveway Entrances and
Sidewalks
3D Sealcoating
3E
Striping, Marking and Signage of Roadways, including pavements
Category 4: Specialty Engineered Earthwork
4A Excavating
4B Clearing and Grading
4C Dredging
LIQUEFIED PETROLEUM GAS CONTRACTORS RECIPROCITY ONLY
LPG Contractor – State License I #601
LPG Service & Installation – State C #408 or A #0803
PLUMBING & SPECIALTY PLUMBING CONTRACTORS
Master Plumber
Irrigation Specialty Contractor
MECHANICAL & SPECIALTY MECHANICAL CONTRACTORS
Mechanical Contractor
Pneumatic Control
Insulation
Sheet Metal
Class A Air Conditioning
Class B Air Conditioning Limited to 25 Tons
Test & Balance – Class A Unlimited
Test & Balance – Class B Limited
Central Vac System
Transport Assembly
ATTACH
TWO
1
½”
x 1
½”
PHOTOS
HERE
5
Notice of Collection of Social Security Numbers for Government Purposes
Under the Federal Privacy Act, disclosure of social security numbers is voluntary unless specifically required by federal statute.
In this instance, social security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654: and
Sections 409.2577 and 409.2598, Florida Statutes, to allow efficient screening of applicants and licenses by a Title IV-D child
support agency to assure compliance with child support obligations. Social security numbers must also be recorded on all
professional and occupational license applications and will be used for licensee identification pursuant to the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act).
Personal Information
Last Name
First Name
Middle Initial
Suffix
Home Address
City
State
Zip
Home Phone
Mobile Phone
Email
Place of Birth
Date of Birth
Social Security Number
Height
Weight
Hair Color
Eye Color
Business Organization Information
I am qualifying as a:
Sole Proprietor
Partnership
Corporation
Business Name
Business Address
City
State
Zip
Business Phone
Business Mobile Phone
Business FAX
Email
Have you ever:
Yes No
Been convicted, adjudication withheld, and/or you plead nolo contendere (no contest) to a felony or first degree misdemeanor,
including but not limited to the following crimes, dishonesty, fraud, deceit, or lack of integrity in the operation or conduct of the
applicant’s business, occupation, or trade. Please provide official disposition documents from the court of law for any
adjudication, conviction, withheld adjudication or nolo contendere.
Date Location Charges Disposition
Yes No
Contracted or done work outside the scope of operation, as set out in the definition of the particular type of contractor for which
you are qualifying?
Abandoned without legal excuse, a construction project or in which you were engaged or under contract as a contractor or
subcontractor?
Diverted Funds or property received for execution or completion of specific construction project or operation, or for a specific
purpose, to any other use whatsoever?
Departed from or disregarded in any material respect, the plans of the owner or his duly authorized representative?
Disregarded or violated in the performance of your contracting business, any of the building, safety, health insurance, or
workmen’s compensation laws of the State of Florida, or the regulations of Broward County?
6
Yes No
Misrepresented any material fact in your application and supporting papers in obtaining a license?
Failed to fulfill your contractual obligation through inability to pay all creditors for material furnished, work or services
performed, in the operation of your business for which you are licensed?
Aided or abetted an unlicensed person to evade the licensing requirements of Broward County, or allowed your license to be
used by an unlicensed person or acted as an agent, partner, or associate of an unlicensed person with the intent to evade the
licensing requirements of Broward County?
Been guilty of any fraudulent act as a contractor or sub-contractor, by which another is substantially injured?
Filed bankruptcy in business?
If you answered yes to any of the above questions, please explain on a separate sheet of paper
Employment History
List your record of employment, beginning with your most recent employer, to demonstrate your practical and required
experience in the construction field. Include any and all businesses that you have owned, operated, managed or you have had
an active part in. Please explain any gaps in employment on a separate sheet. If your employment history exceeds the space
provided, please provide on an additional sheet and attach to this application.
Employer 1
Date Hired
End Date
Business Name
Business Address
City
State
Zip
Business Phone
Business Mobile Phone
Business Email
Last Position Held
Reason for Leaving
Specify Type of Work
7
Employer 2
Date Hired
End Date
Business Name
Business Address
City
State
Zip
Business Phone
Business Mobile Phone
Business Email
Last Position Held
Reason for Leaving
Specify Type of Work
Education History
College
Name
Address
City
State
Zip
Degree
Trade School
Name
Address
City
State
Zip
Degree/Certification
8
High School
Name
Address
City
State
Zip
Degree
Certificates of Competency
Certificate Type
Certificate Number
Date Issued
Date Expires
Place Issued
By Exam
Yes No*
Yes No*
Yes No*
*If not issued by exam, please explain:
Are you aware that all answers made on this application constitute a sworn statement by you?
Yes
No
I certify that the above information and any attachments to this application are true and correct under penalty of law.
I further understand that the Broward County Building Code Services Division may deny this application based on
my history, failure to disclose information, and/or information that is false or misleading.
Applicant’s Signature
Date
NOTARY PUBLIC
State of Florida )
) SS
County of )
The foregoing instrument was acknowledged before me this ____ day of __________________, 20___, by _______________________
wh
o is personally known to me, or who has produced ___________________________________________________________________
a
s identification, and who did take an oath.
__________________
____________________
(Seal) Notary Public in and for the State of Florida
9
Affidavit of Experience
Provided by:
Employer Self Employed Employer No Longer in Business
This is to certify that:
Is/was employed by
Business Address
City
State
Zip
From
To
Total Length of Time
The specific type of work performed consisted of the following:
Remarks (if any)
I am the qualifier for the above mentioned firm or corporation and hold a current Certificate of Competency
Card Number
Issued By
Type of Contractor
Contact Phone Number
Contractor Name
By signing this affidavit, I understand that if I am found to be providing false statements related to the applicant’s
experience and competency, then as a contractor licensed by Broward County I face penalties up to and including
licenses suspension and revocation. If I am licensed by another county, state, or professional agency other than
Broward County, then I understand a letter from the Contracting Licensing Board for the General Construction and
Specialty Trades will be sent to my licensing authority making them aware of any false or misleading statements I
may have made in this affidavit.
Contractor’s Signature
Date
NOTARY PUBLIC
State of Florida )
) SS
County of )
The foregoing instrument was acknowledged before me this ____ day of __________________, 20___, by _______________________
w
ho is personally known to me, or who has produced ___________________________________________________________________
a
s identification, and who did take an oath.
__________________
____________________
(Seal) Notary Public in and for the State of Florida
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Engineering Mechanical Electrical Plumbing Specialty Plumbing and Liquefied (Broward County)

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Completed 27 August 2020

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