Fillable Experience Journeyman Certificate of Competency Application Information and (Broward County)

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Experience Journeyman Certificate of Competency Application Information and (Broward County)

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Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION
1 North University Drive, Box #302 • Plantation, Flor
ida 33324 • 954-765-4400 • broward.org/building
Journeyman
Certificate of Competency Application Information and Instructions
Experience
To appl
y for a Journeyman license, you must have experience in the electrical, mechanical or plumbing
trade as outlined below:
•
Specialty Electrical Journeyman: must have at least three years of practical experience in
the fire alarm industry, limited energy systems industry (f/k/a low voltage) or solar
photovoltaic industry in addition to all State of Florida requirements.
•
Electrical Journeyman; Maintenance Electrician: must have at least four years practical
electrical maintenance experience.
•
Mechanical Journeyman: must have at least three years of experience in the mechanical
field (includes mechanical, insulation or sheet metal).
•
Plumbing Journeyman: must have at least four years of practical plumbing experience in
the plumbing field.
Proof of Experience
You must submit a notarized affidavit to substantiate the required experience by your present or former
licensed employer. If you are employed by Broward or Miami-Dade County School Board, you
must submit a signed and notarized affidavit, on official letterhead, from a licensed contractor
that you worked under for the time you have been employed there. The affidavit must include a
statement indicating that the licensed person is an employee of the School Board.
Reciprocity applicants must also submit a notarized affidavit. In addition, some boards may require you
to appear before them.
All letters and affidavits must be notarized
• Electrical Journeyman; Maintenance Electricians: must include copies of your last 4
years of W-2 forms.
• Specialty Electrician: must include copies of your last 3 years of W-2 forms.
• Mechanical Journeyman: must include copies of your last 3 years of W-2 forms.
• Plumbing Journeyman: must include copies or your last 4 years W-2 forms.
Print
2
Photographs
You must include two passport-sized photos of yourself taken within the last 3 months.
Processing Fees
• Electrical $115
• Mechanical $120
• Plumbing $115
Please make checks payable to: Broward County Board of County Commissioners
All fees are Non-Refundable
Notification
After the Board reviews this application, you will be advised of their decision via letter. Should your
application be denied by the Board, this fee will not be refunded. However, you may provide additional
information requested by the Board and your file will be reconsidered for approval to take the exam at
no further cost.
Testing
Once approved, your contact information will be sent to the testing agency .A minimum passing grade
of 75% is required.
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.
3
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
Journeyman
Application for Certificate of Competency
New License
License by Reciprocity
Journeyman Classification:
Electrical Journeyman
Electrical Journeyman: Fire Alarm Systems
Electrical Journeyman: Limited Energy Systems
Solar Photovoltaic Systems Specialty Journeyman
Maintenance Electrician
Mechanical Journeyman
Plumbing Journeyman
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
ATTACH
TWO
1
½”
x 1
½”
PHOTOS
HERE
4
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
y
ou 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?
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
5
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
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
6
Education History
College
Name
Address City State Zip
Degree
Trade School
Name
Address City State Zip
Degree/Certification
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 underst
and 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.
Signature Date
NOTARY PUBLIC
State of Florida )
) SS
County of )
The foregoing instrument was acknowledged before me this ____ day of __________________, 20___, by _______________________
who is personally known to me, or who has produced ___________________________________________________________________
as identification, and who did take an oath.
______________________________________
(Seal) Notary Public in and for the State of Florida
7
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
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.
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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Completed 27 August 2020

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