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NEVADA STATE CONTRACTORS BOARD (Nevada State Contractors Board)

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Nevada State Contractors Board Revised 10/19
Application to Activate an Inactive Status License
Page 1 of 6
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, STE. 200, HENDERSON, NEVADA, 89074, (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
APPLICATION TO ACTIVATE AN INACTIVE STATUS LICENSE
This application must be made within eight (8) years from the date that the inactive status was granted. If it has been more
than eight (8) years, you must reapply. If subsequent to receiving an inactive status, your license was suspended, revoked, or
otherwise disciplined, you may not be eligible to reinstate this license.
You cannot engage in any work or activities that require a contractor’s license until this application has been approved, and the
license has been returned to active status.
If there has been a change in your business entity, for example, you have formed a partnership or a corporation, or if
a partner has been added to or deleted from your business, you will be required to apply for a new license.
General Instructions
1. Please type or print in ink when completing this form.
2. Make sure the application is properly signed.
3. Read all instructions carefully, and include all required supporting documentation. The Board desires to provide courteous
and timely service to all applicants. To maximize its efficiency and the level of service, the Board will process complete applications
only. Incomplete applications will be returned to you.
4. Leave no space blank. If a particular question or request for information does not apply to you, put a short line in the blank space
to indicate the question has received your attention.
5. Attach any additional supporting applications that may be necessary.
6. Renewal Fees: Please contact an office of the Board for a determination of the appropriate Renewal fee.
Legal Business Name: _________________________________________________________________
(Use name as it currently appears on the records of the NSCB)
Principal Place of Business (Is this a new address Yes No)
Physical Address: _______________________________________________________________________
Street Address City County State Zip Code
Mailing Address: ________________________________________________________________________
Street Address or P.O. Box City County State Zip Code
License Number: _____________________ Phone: _____________________________
(A separate application is required for each license)
Facsimile: __________________________
E-mail address:______________________
SECTION 2 – RESIDENT AGENT
Resident Agent: You must provide the name of a person physically located in the State of Nevada for service of process, including the
street address or other physical location in the State of Nevada and, if different, the mailing address.
Name of Resident Agent: _____________________________________________________________________________
Physical Address: ___________________________________________________________________________________
(Street Address) (City) (State) (Zip)
Mailing Address: ____________________________________________________________________________________
(Street Address or P.O. Box) (City) (State) (Zip)
Nevada State Contractors Board Revised 10/19
Application to Activate an Inactive Status License
Page 2 of 6
SECTION 3 – PERSONNEL
This form cannot be used to change the personnel of the license. If there has been a change in personnel you must complete and attach the
appropriate application(s) when submitting this form.
Corporation: If there has been a change in corporate officers, a change of officer application will be required.
Limited Liability Company: If there has been a change in the managers and/or members, a change of member/manager application
will be required.
SECTION 4 – GENERAL QUESTIONS
AL
L OF THE FOLLOWING QUESTIONS PERTAIN TO THE LICENSEE AS WELL AS EACH MEMBER OF THE PERSONNEL. EACH
QUESTION MUST BE ANSWERED. ANY AFFIRMATIVE ANSWER REQUIRES SUPPORTING DOCUMENTATION.
1. Ar
e there now any unpaid past due bills for either materials, services rendered, or labor for work performed in Nevada or any other state?
No Yes - If “yes” attach a detailed explanation.
2. Are there any judgments, suits or claims (including tax claims) pending or recorded against you, which remain unsatisfied?
No Yes – If “yes” attach a detailed explanation.
3. Are there currently any liens or stop notices for labor or materials filed on any of your work in Nevada or any other state?
No Yes – If “yes” attach a detailed explanation.
4. Since your license has been inactive, have you filed or been adjudicated bankrupt under your individual name, a corporate name or any
other business entity name?
No Yes – If “yes” attach a complete copy of the petition, including the schedule of creditors listed in the bankruptcy
petition.
5. Since your license has been inactive, have you pled “guilty” or “no contest” to, or been convicted of a crime?
No Yes – If “yes” attach a detailed explanation, including copies of the original complaint information or indictment
and final judgement or conviction for any/and all arrests.
SECTION 5 - BOND REQUIREMENT
If
you were required to maintain a bond at the time inactive status was granted, you must provide a bond when this application is approved in
that same amount. You may provide a surety bond (form available from our web site www.nscb.nv.gov) executed by a surety company and
counter signed by a Nevada agent, or a cash deposit (cashier’s check or money order) for the full amount of the bond.
SECTION 6 – REGISTRATION WITH THE NEVADA SECRETARY OF STATE
Nevada Business ID: _________________________________________
All businesses are required to have a Nevada State Business License which has a unique Nevada Business ID. Contact the Nevada Secretary
of State to obtain a Nevada State Business License. They can be reached at (702) 486-2880 or www.sos.state.nv.us.
CO
RPORATIONS; LIMITED LIABILITY COMPANIES; AND LIMITED PARTNERSHIPS
You are required to attach a certificate of good standing issued by the Nevada Secretary of State.
SECTION 7 – CHILD SUPPORT INFORMATION STATEMENT
SOLE PROPRIETORSHIPS: You are required by Federal and State law to complete the Child Support Information Statement questionnaire by
marking the appropriate response to one of the following statements:
I am
not subject to a Court Order for the support of a child.
I am
subject to a Court Order for the support of one or more children and I am in compliance with that Order; or I am in
compliance with a plan approved by the District Attorney or other public agency enforcing the Order for the repayment of the
amount owed pursuant to that Order.
I am subject to a Court Order for the support of one or more children and I am not in compliance with the Order or a plan
approved by the District Attorney or other public agency enforcing the Order for the repayment of the amount owed pursuant
to that Order. Note: If you have marked this response you should contact the District Attorney or other public agency
enforcing the order to determine the actions that you may take to satisfy the Order.
Nevada State Contractors Board Revised 10/19
Application to Activate an Inactive Status License
Page 3 of 6
SECTION 8 – FINANCIAL STATEMENT REQUIREMENTS
1. Financial Statement Requirements: You must submit a current financial statement (statement) with this application that
meets the following criteria.
• Financial statements must be for the applying entity. Sole proprietorships and each general partner of a general
partnership must submit their personal statement.
• All statements must be in U.S. dollars.
• Business statements must include a classified balance sheet.
• Personal statements that have been prepared by a Certified Public Accountant must include a supplemental
schedule disclosing working capital and net worth.
For License Monetary Limits of $10,000 or less you must provide one of the following:
• A current financial statement prepared by an independent certified public accountant; or
• A current financial statement submitted on a form prescribed by the Board (available on the Board’s website www.nscb.nv.gov
,
click on contractor forms); or
• A current financial statement (Balance Sheet) prepared using accounting software in accordance with generally accepted
accounting principles and accompanied by an affidavit that verifies the accuracy of the financial statement.
*To prevent a delay in the processing of your application, if you are unfamiliar with preparing your own financial
statement, you are encouraged to seek the advice of an Accountant.
Note: Self-prepared or compiled statements must be current to within six months from the date the application is
received.
For License Monetary Limits more than $10,000 but less than $50,000 you must provide one of the following:
• A compiled financial statement prepared by an independent certified public accountant, current within 6 months from the date
the application is received; or
• A reviewed or audited financial statement, prepared by an independent certified public accountant, current within one (1) year
from the date the application is received.
For License Monetary Limits of $50,000 or more but less than $250,000 you must provide one of the following:
• A compiled financial statement with full disclosures, prepared by an independent certified public accountant, current within 6
months from the date the application is received; or
• A reviewed or audited financial statement, prepared by an independent certified public accountant, current within one (1) year
from the date the application is received.
For License Monetary Limits of $250,000 or more: you must provide a financial statement that is prepared and reviewed or
audited by an independent certified public accountant, current within one (1) year from the date the application is received.
2. Bank Verification Form: The bank verification form found on page 6, must be completed by your bank and submitted with
your application.
3. Indemnification Option: Indemnification allows the Board to consider the financial strength of an individual or entity in
addition to the applicant. The indemnification is not required, however, provides an option to an applicant who may not
otherwise qualify. The agreement must be on a form prescribed by the Board, and accompanied by a financial statement and
bank verification form. Financial statements must meet the same criteria as set forth above. Indemnification forms are
available on the Board’s website.
Nevada State Contractors Board Revised 10/19
Application to Activate an Inactive Status License
Page 4 of 6
SECTION 9 - PROOF OF INDUSTRIAL INSURANCE (Commonly known as worker’s compensation):
You must include one of the following as proof of compliance with the laws of the State of Nevada regarding industrial insurance. Mark
the appropriate box, and attach the required certificate or policy.
A copy of your current worker’s compensation policy issued by an agent authorized to write worker’s compensation Insurance in the
State of Nevada.
A copy of your current certificate of qualification as a self-insured employer issued by the commissioner of insurance.
If you are a member of an association of self-insured public or private employers, a copy of the current certificate issued to the
association by the commissioner of insurance; or If applicable, you may sign the affidavit of exemption that follows:
AFFIDAVIT OF EXEMPTION FROM INDUSTRIAL INSURANCE REQUIREMENT
I do hereby swear under penalty of perjury that all of the assertions of this affidavit are true and correct.
I / we are not subject to the provisions of chapters 616A to 616D, inclusive or 617 of NRS;
I / we do not have any employees;
I / we do not intend to be a subcontractor for a principal contractor; and
I / we do not intend to submit a bid on a job for a principal contractor or subcontractor.
I further certify that I have contacted the Industrial Insurance Regulation Division of the State of Nevada regarding my insurance
requirements. I also understand my obligation to comply with the laws of the State of Nevada regarding industrial insurance at
all time.
_____________________________________ ____________________________________
(Signature) (Print Name)
SECTION 10 – RESIDENTIAL RECOVERY FUND
All licensees must complete the following questionnaire.
Residential Contractor Defined: NRS 624.450 defines residential contractor as a contractor who is licensed pursuant to NRS 624 and
who contracts with the owner of a single family residence to perform qualified services.
Qualified Services Defined: NRS 624.440 defines qualified services as any construction, remodeling, repair or improvement
performed by a residential contractor on a single family residence occupied by the owner of the residence.
Assessments are based on your license limit as follows:
• If your license limit is $1,000,000 or less you are required to pay a biennial assessment of $80.00.
• If your license limit is more than $1,000,000 but not unlimited you are required to pay a biennial assessment of $200.00.
• If you license limit is “unlimited” you are required to pay a biennial assessment of $400.00.
1. Will this licensee perform “qualified services” as defined in NRS 624.440?
No Yes
2. Has this licensee, any officer, director, partner, proprietor, shareholder (unless publicly traded), member, owner, qualified
employee, or manager associated with or employed by the applicant ever applied for or become registered in the Residential
Recovery Fund under any name other than the name listed on this application?
No Yes – Provide Name: _________________________ License #:__________________
3. Does this licensee, any officer, director, partner, proprietor, shareholder (unless publicly traded), member, owner, qualified
employee, or manager associated with or employed by the applicant have any claims currently pending before the
Residential Recovery Fund or prior claims paid from the Residential Recovery Fund?
No Yes – Provide case # _________________________
4. Is this licensee exempt from registration with the Residential Recovery Fund?
No Yes
Nevada State Contractors Board Revised 10/19
Application to Activate an Inactive Status License
Page 5 of 6
SECTION 11 - QUALIFIED INDIVIDUAL(S)
PLEASE NOTE: THIS FORM CANNOT BE USED TO CHANGE YOUR QUALIFIED PERSON. IF THE ORIGINAL QUALIFIED
INDIVIDUAL(S) ARE NO LONGER ASSOCIATED WITH THIS LICENSE, YOU MUST FILE A COMPLETED CHANGE OF QUALIFIER
APPLICATION WITH THIS FORM.
All persons who qualified this license, in either the management and/or trade capacity, while the license was active must recommence
their duties as the qualified individual. Each qualified Individual to this license must sign the statement below.
I certify under penalty of perjury that I will act in the capacity of the qualified individual for this licensee, and perform the duties required
of me pursuant to Chapter 624 of the Nevada Revised Statutes and Nevada Administrative Code.
__________________________________________ __________________________________________
(Signature) (Signature)
__________________
________________________ __________________________________________
(Print Name) (Print Name)
SECTION 12 - AFFIDAVIT AND AUTHORIZED SIGNATURE
I am authorized to sign this Affidavit and Release Authorization on behalf of the licensee described and identified in this application.
To the best of the licensee’s / applicant’s knowledge, the information contained in the application and its supporting documents are free
of fraud, misrepresentation, or omission of material fact. To the best of the licensee’s / applicant’s knowledge, the information contained
in the application and its supporting documents are truthful, correct, and complete; and, disclose all material facts regarding the applicant
and associated individuals necessary to properly evaluate the applicant’s qualifications for licensure.
The licensee / applicant will ensure that any information subsequently submitted to the Board in conjunction with this application or its
supporting documents meet the same standard as set forth above.
The licensee / applicant understands that this application will be classified as a public record and will be available for inspection by the
public, except with regard to the release of information classified as confidential pursuant to NRS 624.110.
The licensee / applicant understands that the Nevada State Contractors Board has the authority to conduct appropriate background
investigations for the purpose of verifying all statements and facts represented in this application and supporting documentation.
Signature Requirements: A principal of the applying company must sign this application.
By: __________________________________ Title: ______________________________
(Signature)
__________________________________ Date: ______________________________
(Print Name)
FOR OFFICIAL USE ONLY – DO NOT WRITE IN THIS SPACE
Date Received:_________ Lic. No.#____________Withdrawn:_____________ Approved: _________________
Bond #:______________________ Effective Date:____________ Surety:_________ Agent:_________
Industrial Insurance: Proof of Coverage Provided ___________ Certificate of Exemption___________
Recovery Fund:
Participant – Amount Received ________ Receipt #________ Certificate of Exemption date__________
Processed By:_________
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
(Rev 10/19)
BANK VERIFICATION FORM
Name of Licensee/Applicant: _________________________________ Date:______________________
Items 1 through 3 of the following report are to be completed by the applicant. Items 4 through 10 are to be completed by the
verifying bank. After completion by you and your bank, submit this form with your application.
1. Name and address of bank: ____________________________________________________
____________________________________________________
____________________________________________________
2. Signatures of account holder(s):
__________________________________ ______________________________________
Signature Print Name
__________________________________
_______________________________________
Signature Print Name
3. Information to be verified:
Type of Account
Account Name
Account Number
TO VERIFYING BANK: Please furnish the information requested below.
4. Classification of Account: Individual Corporation Partnership
Limited Partnership Limited Liability Company
5. Deposit accounts of applicants:
*Account Name Type *Account Number *Current Balance
*Six (6) Month
Average
*Date Opened
*Required Information
6. Verification of Lines of Credit:
Line of Credit
Account #
Type of
Credit Line
Date
Opened
Approved
Amount
Current
Balance
Payments Required Secured by
$ Per
$ Per
7. Additional information that may be of assistance in determination of credit worthiness:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8. Affix Bank Stamp or Business Card 9. Name and Title of Bank Representative
of Bank Representative here
__________________________
__________________________
10: Date: ________________________
Nevada State Contractors Board
Application to Activate an Inactive Status License
Pag
e 6 of 6
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