State License #:__________________________
Contractor/License Holder Name:_____________________________________________________________
Mailing Address:___________________________ City:___________________ State:______ Zip:___________
Cell Phone #:________________________ Email:_________________________________________________
Drivers License #:_______________________________
Business Name:____________________________________________________________________________
Business Address:__________________________ City:___________________ State:______ Zip:___________
Business Phone #:_______________________ County:____________________
1. Current copy of State Certified License
2. Certificate of Liability Insurance and Workers Compensation with Hernando County Building
Division, 789 Providence Blvd., Brooksville, FL 34601 as the Certificate Holder
3. Color copy of current Driver’s License or photo ID
4. All fields are required to be filled in
5. Email all items at one time to BLDG@hernandocounty.us
I hereby confirm the above stated information is true and correct to the best of my knowledge.
License Holder Signature
STATE OF __________________ COUNTY OF ___________________
Sworn to (or affirmed) and subscribed before me by means of physical presence or online notarization,
this _____ day of ____________________ , 20____ , by ____________________________.
_______________________________ ____________________________________
Signature of Notary Public Print, Type, or Stamp Commissioned Name of Notary Public
Personally Known OR Produced Identification
Type of Identification Produced____________________
Hernando County Building Division
789 Providence Blvd.
Brooksville, FL 34601
(352) 754-4050
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