Fill - Free fillable NEVADA STATE CONTRACTORS BOARD PDF form

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 1 of 26

NEVADA STATE CONTRACTORS BOARD

2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150

Website: www.nscb.nv.gov

IMPORTANT NOTICE

Dear Applicant:

Thank you for your interest in applying for a contractor’s license in the State of Nevada. The Board desires to

provide courteous and timely service to all applicants. To maximize its efficiency and level of service, the Board

will process complete applications only.

Many applications are rejected because they are incomplete or do not include the required supporting documents.

An incomplete application can needlessly delay you receiving your license. Delays can last several weeks or

even months and possibly result in the application being voided and application fee forfeited.

Spending a few extra minutes now may save you weeks or months later!

Before you submit your application:



 Carefullyreadtheapplicationpackageandfollowthespecificinstructioncontainedthroughouttheform

 Makesuretheapplicationisproperlysigned.

 Includethenon‐refundable$300.00applicationfee.(A$600.00bienniallicensefeewillberequiredafter

yourapplicationisapproved,beforeyourlicensecanbeissued.)

 Filloutallapplicableinfor

mation

 Attachrequiredsupportingdocumentation

 MakesuretherequiredReferenceCertificatessubstantiate aminimumfouryearsofexperienceinthe

classificationforwhichyouareapplyi

ng.

 Fingerprints:



Allapplicants

arerequiredtosubmittheirfingerprints forthepurposeofconductingacriminal

backgroundcheck.(SeeFingerprintingSectionoftheApplication)

Applicantscansubmitelectronicfingerprints throughaLiveScanvendorintheStateofNevada

OR,

Applicantscansubmit

ONE (1) hard copy card taken by thelawenforcementagency.You

MUSTPROVIDEacashier’scheckormoneyorderintheamountof$40.00madepayabletothe 

NevadaDept.ofPublicSafety.PERSONALCHECKSORCASHWILLNOTBEACCEPTED.



Nevada State Contractors Board

New License Application (Revised 9/14)

Page 2 of 27

NEVADA STATE CONTRACTORS BOARD

2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150

Website: www.nscb.nv.gov

APPLICATION FOR CONTRACTOR’S LICENSE

i Read all instructions carefully. 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. A complete application includes all

applicable supporting documents and fees. The Board will not act as your agent in gathering information or supporting documents

necessary for the consideration of your license application. Incomplete applications will be returned to you.

i Please type or print in ink when completing this form.

i Make sure this application is properly signed.

i Include the nonrefundable application fee of $300.00. (A $600.00 biennial license fee will be required after approval of

your application, before your license can be issued.)

i Leave no space blank. If a particular question or request for information does not apply to you, put “N/A” in the blank space to

indicate the question has received your attention.

SECTION 1 – BUSINESS NAME AND ADDRESS

Business Name: The legal business name is the name that will appear on the license and is the actual name under which the

contracting business will be conducted. If you will be using a fictitious business name (doing business as), list that name also, and

include a filed copy of your fictitious name certificate.

Name Similarity: To determine if another contractor is using a similar name, please visit the NSCB website @ www.nscb.nv.gov and

search by contractor name. If the Board determines that a licensed contractor is using a similar business name, you will be requested to

choose a different name.

Legal Business Name: ______________________________________________________________________

Address: Space is provided for two addresses, a mailing address and a physical location address. The mailing address is the address

where the Board will send all mail. The physical location address is the address where your business is physically located, and may be

contacted for service of process. They may be the same address, but at least one address must be a physical location, not a post

office box or mail drop.

Principal Place of Business

Physical Address:____________________________________________________________________

(Street Address)

_______________________________________ ___________________ ________________

(City) (State) (Zip)

Mailing Address: ________________________________________ ________________________ ___________ __________

(Street Address or P.O. Box) (City) (State) (Zip)

Phone No.: (_____)________________ Facsimile No.: (_____)________________ Email: _______________________________

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.

SECTION 2 - SERVICE OF PROCESS

Provide the name and address of a person physically located in this State for service of process on the applicant.

Name: _______________________________________________________

Address: ___________________________________________ ________________________, Nevada,

__________

(Street Address) (City) (Zip)

Red Bordered Fields are Required

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 3 of 26

SECTION 3 - PERSONNEL

Personnel: Supply the identifying information below for all: Elected officers, if a corporation; all partners, if a partnership;

the sole proprietor, if applying as an individual; persons who are members and/or managers, if a limited liability company;

and your qualified employee(s).

Limited Liability Companies: If any of your members are legal entities, or if your LLC has elected officers, please

include an organizational chart identifying the individuals associated with the member entities.

Background Disclosure Statement: A separate background di

sclosure statement must be completed

by each principal,

member, officer, director, partner, or a

ssociate of this applicant, includin g an y qualified employees, accompanied by a

copy of either a valid state driver’s license

or valid government issued photo

I.D. card (Sole Proprietors must include

spouse).

Fingerprints: Each principal, member, officer, director, partner, or associate of this applic

ant, includin

g any qualified

employees are required to submit their fingerprints for the purpose of conducting a criminal background check.

FIRST NAME MIDDLE NAME LAST NAME TITLE

(Attach a separate sheet if necessary)

SECTION 4 – BUSINESS ENTITY TYPE

Business Entity: Licenses are issued to legal business entities, and are not transferable from one entity to another. It is

suggested that you consult with your legal counsel and/or accountant when deciding on the business entity type.

Check appropriate business entity:

Sole Proprietor - If you are applying as a sole proprietor, you must complete and submit the Child Support

Information Statement found on page 17, and Background Disclosure Statement for spouse if applicable.

Corporation - Include a copy of your certificate of good standing issued by the Nevada Secretary of State, and the

name and address of your resident agent. The Nevada Secretary of State can be contacted at (775) 684-5708 or

www.sos.state.nv.us.

Limited Liability Company – Include a copy of your certificate of good standing issued by the Nevada Secretary of

State, and the name and address of your resident agent.

Limited Partnership – Include a copy of your certificate of good standing issued by the Nevada Secretary of State,

and the name and address of your resident agent.

General Partnership – Tax ID number __________________.

Joint Venture – Tax ID number _____________________.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 4 of 26

SECTION 5 – CLASSIFICATION OF LICENSE REQUESTED

State the classification of contractor’s license you are applying for. You will find a classification list on pages 18 and 19.

For a complete description of each classification visit the Board’s website.

Classification Requested: _________________________________________________

Note: If you are applying for a license to engage in the repair, restoration, improvement or construction of residential

pools or spas, please read the informational statement concerning contract and bond requirements found on our website.

Explain briefly the purpose of applying for this license, the approximate size and type of projects you contemplate

building.

________________________________________________________________________________________________

SECTION 6 – CONTRACTOR’S LICENSES

List all contractor licenses, regardless of the current status, held by this applicant, or any individual appearing on this

application. Include licenses held in Nevada and any other state.

Company Name State Lic. No. Issue Date License Status

SECTION 7 - ASSOCIATES

This section is applicable only if the applicant is a corporation, limited liability company, or limited partnership. Do any

persons (other than those listed in section3) own 25% or more of: a) The stock in the corporation, b) interest in the limited

liability company, or c) interest in the limited partnership.

 No  Yes – If yes, list names and percentage owned.

__________________________________

SECTION 8 – MONETARY LIMIT REQUESTED

Monetary Limit: The mo netary limit is the maximum contract a licensed contractor may undertake on one or more

construction contracts on a single con

struction site or subdivision site for a single client. It is a violation of Nevada law to

bid or contract in excess of the limit

placed on the license by the Board.

The monetary limit is determined by consideration of the factors set forth in NRS 624.260, 624.263, and 624.265. (Copies

of these statutes are available from our website).

State the monetary limit desired: __________________________

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 5 of 26

SECTION 9 - FINANCIAL RESPONSIBILITY 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 21, 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

New License Application (Revised 9/14)

Page 6 of 26

SECTION 10 – EXPERIENCE QUALIFICATIONS

Qualified Employee (Qualifier): The qualifier can be an owner, officer, member, manager or employee of the company.

You may have more than one qualified employee. Each qualifier must be a bona fide member or employee of this

company, and when you are actively engaged in the contracting business, the qualified employee shall exercise authority

in the following manner:

 To make technical and administrative decisions;

 Hire, superintend, promote, transfer, lay off, discipline or discharge other employees and direct them, either by

himself or through others, or effectively to recommend such action on behalf of this company; and

 To devote himself or herself solely to this business, not taking any other employment that would conflict with his

or her duties.

Previously Qualified and Reciprocal Applicants: The Reference Certificates and Resume of Experience will not be

required if you:

1. Have served as a qualified employee in the same classification on another Nevada state contractor’s

license within the last five ( 5) years; or,

2. If you meet the terms of reciprocity described in section 11.

Management Qualifier: This individual must take and pass the construction management survey examination. This

exam includes topics such as general knowledge of the Nevada contractors’ law, mechanics lien law, laws regarding

industrial insurance, and common knowledge of business administration.

Trade Qualifier: This individual must have, within the 10 years immediately preceding the filing of this application, at least

4 years of experience as a journeyman, foreman, supervising employee or contractor in the specific classification

requested.

Training received in a program offered at an accredited college or university or an equivalent program accepted by the

Board may be used to satisfy not more than 3 years of experience.

A “journeyman” is defined as a person who is fully qualified to perform, without supervision, work in the classification

applied for; or has successfully completed a program of apprenticeship that has been approved by the state

apprenticeship council, or equivalent program accepted by the Board.

*If there are multiple sub-classifications within the classification for which you are requesting, the trade qualifier must

substantiate experience for the full scope of your license. Separate qualifiers for individual sub-classifications are not

allowed.

Reference Certificates: You are required to submit with this application, four (4) Reference Certificates (certificates) for

each trade qualifier. The certificates should be completed by employers, other than the applying company, or if a self-

employed contractor, by customers for whom the work was performed. The certificates must verify the experience

requirements as stated above. Relatives cannot complete the certificates, unless that relative was your employer.

References that are not complete or not specific regarding the actual work performed will not be accepted.

Any reference

determined to be false or misleading may be considered misrepresentation of a material fact, in violation of NRS

624.3013(2). The required certification forms are on pages 22 – 25.

Resume of Experience: Complete the Resume of Experience form found on page 26 for each trade qualifier. Include

name, current address, phone number and dates of employment for each employer. Describe in detail the work

performed. Specify type(s) of construction projects, trades(s), craft(s), tasks and duties performed. If self-employment is

being relied upon to establish any portion of the experience requirement, include on the Resume’ of Experience form

customers for whom you worked, including their complete mailing address and phone number.

Important Notice: If for any reason your qualified employee(s) terminates his or her employment or association with this

license you are required to notify the Nevada State Contractors Board, in writing, within ten (10) days, and replace that

individual(s) within 30 days. Failure to do so will result in automatic suspension of the license.

Ownership Requirement: A qualified individual may not qualify on behalf of another for more than one active license

unless that individual owns at least 25% of each licensee for which he or she qualifies; or one licensee owns at least 25%

of the other licensee. If you will be qualifying more than one active license

, other than a sole proprietorship owned by you,

attach proof of ownership for each license.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 7 of 26

SECTION 11 – EXAMINATION REQUIREMENTS

Examination Requirements: A management (CMS) and trade examination will be required. The trade exam will be

specific to the classification requested. A test registration form will be provided to you after the application is submitted

and experience is verified. Candidate information, exam content outlines, and order forms for the “CMS” exam reference

manual are available on the Board’s website.

Exam Fees: Examination fees are due when you register to take your exam(s) and are payable to PSI. The fee is $95.00

for each exam. If you schedule the CMS and

one trade exam at the same time, the fee for both exams is $140.00.

Waiver of Examination: You may be eligible for waiver of the examination(s) if you meet the following qualifications:

Nevada Licensure: If, within the last five (5) years, you have served as a qualified employee on a license in the State

of Nevada in the same classification for which you have applied.

I am applying for exam waiver based on prior qualification in the State of Nevada on license

number(s) ____________________________________

Reciprocal Agreements: Nevada has limited reciprocal agreements with the states of Arizona

, California, and Utah.

This agreement applies to the trade examination only

. This act of reciprocity does not include any of the plumbing,

electrical, or fire protection trades. Technical exams will be required for those classifications deemed to fall within these

trades. To be considered for reciprocity, the following is required:

 The trade qualifier must have held a license which has been active and in good standing, in one of the participating

states for at least five (5) out of the last seven (7) years.

 The trade qualifier must have taken and passed an equivalent examination in that state.

 Proof of compliance with the above stated requirements must be submitted with the application.

I am applying for waiver based on reciprocity with the state of ___________. I have attached proof

of compliance with the above stated requirements using the out of state license verification form found

on page 20. If applying for a general building license indicate whether or not you construct buildings

which exceed three (3) stories in height.

Yes No

The Nevada State Contractors Board reserves the right to require an examination of any applicant regardless of

current or previous licensure.

The State Contractors Board is not affiliated with and does not endorse or recommend any contractors licensing

schools or services. Please direct any questions regarding your application and exam requirements to the State

Contractors Board.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 8 of 26

SECTION 12 - SIGNATURE OF QUALIFIED EMPLOYEE AND CERTIFICATION OF DUTY

 I certify under penalty of perjury that I will act in the capacity of the qualified employee for this licensee and perform the duties

required of me pursuant to Chapter 624 of the Nevada Revised Statues and Nevada Administrative Code, Chapter 624. If at any

time I cease to be employed by, or associated with this company, I will immediately provide written notification to the State

Contractors Board.

(TWO SPACES ARE PROVIDED IN THE EVENT YOU HAVE MORE THAN ONE QUALIFIER)

I will be acting in the following capacity:

Management Qualifier (This is the individual that will take or has already taken the construction management examination)

Trade Qualifier (This is the individual that has demonstrated the necessary technical experience, and will take or has

already taken the trade examination.)

Both Management and Trade Qualifier

_____________________________________ _________________

(Signature) (Date)

__________________________________________

(Print Name)

I will be acting in the following capacity:

Management Qualifier (This is the individual that will take or has already taken the construction management examination)

Trade Qualifier (This is the individual that has demonstrated the necessary technical experience, and will take or has

already taken the trade examination.)

Both Management and Trade Qualifier

_____________________________________ ________________

(Signature) (Date)

__________________________________________

(Print Name)

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 9 of 26

SECTION 13 – RESIDENTIAL RECOVERY FUND

The State of Nevada has established a residential recovery fund for the benefit of Nevada homeowners who contract

with a licensed contractor and, under certain conditions, are harmed by the failure of that contractor to properly perform

qualified services.

The fund i s created from assessments of contractors who partici pate in the co nstruction, remodeling, repair or

improvement to residential housing. Assessments are based on the monetary limit placed on the license.

Who Must Register With the Fund: Each residential contractor who will be providing “Qualified Services” must register

with the Fund. Qualified services are defined in NRS 624.440 a s “any construction, remodeling, repair or improvement

performed by a residential contractor on a single family residence occupied by the owner of the residence”. A residential

contractor is defined in NRS 624.450 as a co ntractor who contracts with the owner of a single-family residence to

perform qualified services.

Prior to issuance of a license, each applicant must either register with the fund or complete a certificate of

exemption. This information will be provided to you once the application is approved.

Answer “yes” or “no” to each of the following questions. Do not leave any question unanswered.

1. Will this applicant act as a “residential contractor” performing “qualified services” as defined in NRS 624.440 and

NRS 624.450?

 No  Yes

2. Does the ap plicant, any officer, direct or, partner, proprietor, shareholder (unless publicly traded), m ember,

owner, qualified employee, or manager associated with or employed by the applicant have any prior claims paid

or claims pending with the Residential Recovery Fund?

 No  Yes – If “yes” Provide Claim # _________________________

SECTION 14 - LICENSE BOND REQUIREMENT

Nevada law requires a license bond for each license issued. The Board determines the amount of the bond at the time

of license approval. The bond can vary in amount from $1,000 to $500,000 based on the type of license, monetary limit,

past, present or future financial responsibility, experience, and character of the applicant.

After license approval, you will receive notification of the amount of bond required. A surety bond or a cash deposit will

be required for that amount.

• Surety bonds must be executed on the form provided by the Board, and written by a surety company with an “A” or

better rating.

• Cash deposits must be in the form of a Cashier’s Check payable to the State Contractors Board for the full amount

of the bond. A biennial administrative fee of $200.00 will be assessed for all cash bond deposits. If you choose to

post a cash deposit, please note that following termination of the license or relief of the bond requirement, the

NSCB is required to hold the cash deposit for an additional two (2) years. The requirement is based on the statute

of limitations for filing claims.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 10 of 26

SECTION 15 – CONSTRUCTION EDUCATION FUND

The Nevada Legislature created a construction education fund for the purpose of funding programs of education which

relate to building construction. The fund is intended to help support construction education programs. Administrative fines

collected by the Board have been “earmarked” for this fund. In addition, individuals may make voluntary contributions. If

you would like to make a voluntary contribution, please submit a separate check made out to “State of Nevada

Construction Education Fund.”

 I have enclosed a voluntary contribution to the construction education fund.

 I have chosen not to contribute to the fund at this time.

SECTION 16 - INDUSTRIAL INSURANCE REQUIREMENTS

Proof of compliance with Nevada laws regarding industrial insurance is required. Please contact the Division of Industrial

Relations for a determination regarding requirements for your company. In the Las Vegas area call (702) 486-9080, and

in the Reno area call (775) 684-7270.

You will be required to provide one of the following as proof of compliance:

 A certificate of liability insurance covering employees for industrial injury and occupational diseases (commonly

known as “workers comp”) written through an authorized carrier for the State of Nevada;

 A copy of your 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 certificate issued

to the association by the Commissioner of Insurance; or

 A signed affidavit stating you are not subject to the provisions of Nevada Revised Statute, Chapter 616A and

616D because: a) you have no employees; b) you will not be a subcontractor for a principal contractor; and c)

you will not submit a bid on a job for a principal contractor or subcontractor. This form will be provided upon

approval of the application.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 11 of 27

SECTION 17 – AFFIDAVIT AND AUTHORIZED SIGNATURE

I am authorized to sign this Affidavit and Release Authorization on behalf of the applicant described and identified in this

application.

The applicant is qualified in all respects for the license for which it is applying in this application.

To the best of 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 applicant’s knowledge, the information contained

in the application and its supporting documents are truthful, correct, and complete; and, discloses all material facts

regarding the applicant and associated individuals necessary to properly evaluate the applicant’s qualification for

licensure.

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.

Applicant understands that to apply for or obtain a license or to otherwise deal with the Nevada State Contractors Board

through the use of fraud, forgery, intentional deception, misrepresentation, misstatement, or omission is cause for denial

of this application.

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. Confidential

information includes credit reports, references, financial information, and investigative memoranda.

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 OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE

Date Received: ________________ Application Fee Paid: _______________ Receipt #: __________________ File No. _______________

Withdrawn: Date: ____________________ Reason: ____________________ Approved: __________________ App. No. ______________

Limit: ____________________ Bond Amount:____________________ CPB Amount: ___________________ Org ID. ______________

Bond #: __________________________ Effective Date: __________ Surety: __________ Agent: ___________ Analyst _______________

Industrial Insurance: Proof of Coverage Provided Certificate of Exemption Entered by: ____________

Recovery Fund: Participant Certificate of Exemption Date ______________________ Date: _________________

License Fee Paid: _________________ Receipt #: __________________ Date Paid: _________________

Issue Date: ________________License Number: _____________________ FS Review Year:_____________

Indemnitor: _________________________________________________________________ Effective:_____________

Name Change: ____________________________________ Entity Type Change: _______

QI:__________________________ CMS TRD; File#:___________ Type: PQ 1020 3030 App #:________________ Status: A D W

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 12 of 26

IMPORTANT NOTICE REGARDING THE BACKGROUND

DISCLOSURE STATEMENT

YOUR APPLICATION MAY BE DENIED IF YOU FAIL TO MAKE FULL AND ACCURATE DISCLOSURES

.

As part of the Nevada State Contractors Board (NSCB) application process, fingerprints are required and

credit reports and criminal history records are obtained.

If you as an individual or principal of a corporation or other business entity have EVER been convicted of, pled

guilty or no contest to the following, you are required to report the information to the NSCB:

1. Any non-violent misdemeanor, including DUI, within the past fifteen (15) years;

2. Any misdemeanor crime involving violence against another person, fraud or theft;

3. Any felony conviction.

You must also provide certified copies of the arrest report and court records for each conviction. You may

also be required to provide copies of the appropriate records reflecting the dismissal or reduction of a

felony arrest.

Your records or fingerprints will be compared to the records of the Nevada Criminal History Repository and

the Federal Bureau of Investigation. If you have EVER been arrested or convicted of a crime in any

state, your prior criminal history arrest and conviction information will be reported to the NSCB.

Please note:

Even if you had your record expunged, charges reduced, dismissed, or sealed, the

conviction may

still be reported to the NSCB and you may be asked to provide additional information to the

Board.

Failure to disclose a conviction is misrepresentation which violates NRS 624.3016(7) and NRS

624.3013(2) and is grounds for denial. This means you could be denied a license even if the conviction is

not related to the duties or qualifications of a contractor.

Just because you have been convicted of a crime does not automatically mean your application will be

denied. When reviewing prior criminal convictions, the NSCB considers such additional factors as the

seriousness of the crime, the time that has passed since the conviction and any evidence of rehabilitation the

applicant submits. However, if you misrepresent, omit or lie on your application, your application may

be denied. If you have any questions concerning the disclosure of arrests or convictions, please call the

Investigations Department of the NSCB, at 702-486-1144 in Henderson or 775-688-7884 in Reno.

DISCLOSE ALL LIENS, LAW SUITS, JUDGMENTS AND CLAIMS, INCLUDING TAX CLAIMS

 You MUST disclose any unpaid or unresolved liens, lawsuits, judgments and claims, including tax

claims.

 You should obtain a copy of your credit report before you complete your application. That will help you

to disclose all unpaid, unresolved liens or claims, all lawsuits, and all judgments. Pay particular

attention to any tax claims or liens that have been made or filed against you.

 If you have entered into any repayment or credit consolidation agreements, attach copies of those

agreements to your application.

 I HEREBY CERTIFY THAT I HAVE READ THIS NOTICE.

NAME:____________________________________ SIGNATURE: _________________________________________

Background Disclosure Statement & Authorization for Release of Information Page 1 of 3

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 13 of 26

NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE

STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION

BUSINESS NAME:

__________________________________________

NRS 624.263 and NRS 624.265 authorizes the Nevada State Contractors Board (NSCB) to conduct background

investigations, obtain credit reports, and to request fingerprints for submission to the Nevada Highway Patrol

(NHP) and the FBI for a determination of identity, fugitive status or prior criminal history.

A separate form must be completed by each principal, member, officer, director, partner, or associate.

***A COPY OF A VALID STATE DRIVER’S LICENSE OR VALID GOVERNMENT

ISSUED PHOTO I.D. MUST ACCOMPANY THIS FORM. ***

1. Have you ever, as an individual or principal of a corporation or other business entity, been convicted of, or pled guilty or no contest to a

felony crime?

 No  Yes – You must complete a criminal disclosure statement for each

incident.

2. Have you ever, as an individual or principal of a corporation or other business entity, been convicted of, or pled guilty or no contest to any

misdemeanor crime? (You may limit your response to misdemeanor convictions within the last 15 years, unless the crime involved

violence against another person, fraud or theft).

 No  Yes – You must complete a criminal disclosure statement for each

incident.

3. Are there currently criminal charges pending against you?

 No  Yes – Attach a detailed explanation, including a copy of the complaint, and/or charging document.

4. Within the last 7 years, have you filed or been adjudicated Bankrupt under your individual name, a corporate name or any other business

entity name?

 No  Yes – Attach a copy of the discharge document. If discharged less than 3 years, attach a complete copy of the

proceedings, including a schedule of creditors listed in the bankruptcy petition. If the bankruptcy has not been discharged, include

your plan of reorganization and proof of compliance.

5. Do you anticipate filing bankruptcy within the next 6 months?

 No  Yes

6. Have you, or any business entities of which you were a member, partner, officer, director, or associate received any notice of liens, suits,

judgments, or claims (including tax claims) which remain unresolved or unsatisfied ? OR, have you entered into payment agreements

regarding past due taxes or other debts?

 No  Yes – Attach a detailed explanation.

7. Are there now any unpaid past due bills for materials, services rendered, or labor?

 No  Yes – Attach a detailed explanation.

8. Have you, or any business entities of which you were a member, partner, officer, director, associate, or qualified employee had a

contractor’s license denied, suspended, revoked, or otherwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any

disciplinary proceedings currently pending against you, or any license on which you have appeared IN NEVADA OR ANY OTHER

STATE?

 No  Yes – attach a detailed explanation including the name of the state in which

the license was held, license number, and

business name.

9. Do you have a proprietary interest (i.e., ownership, stock, shares) in this applicant? (This question does not pertain to sole proprietors)

 No  Yes – Percentage Owned _________________

10. Are you a citizen of the United States of America?

 No  Yes – If no, attach a copy of INS card and Social Security Card.

Background Disclosure Statement & Authorization for Release of Information Page 2 of 3

FIRST NAME

MIDDLE NAME LAST NAME

TITLE

DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER

OTHER NAME USED, (IF APPLICABLE) SEX RACE HEIGHT WEIGHT HAIR COLOR EYE COLOR

RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT) CITY STATE ZIP

EMAIL ADDRESS

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 14 of 26

Applicant Background Disclosure Statement

Authorization for Release of Information (continued)

In Consideration for processing my application for a Nevada State Contractor’s License, I, the undersigned whose name

and personal information voluntarily appear above, do hereby and irrevocably agree to the following:

1. I hereby authorize the NEVADA STATE CONTRACTORS BOARD (hereinafter “BOARD”) to submit a set of my

fingerprints to the Nevada Department of Public Safety, Records Bureau for the purpose of accessing and reviewing

Nevada and National criminal history records that may pertain to me. In giving this authorization, I expressly

understand that the information may include information pertaining to notations of arrest, detainments, indictments,

information or other charges for which the final court disposition is pending or is unknown to the above referenced

agencies. For records containing final court disposition information, I understand that the release may include

information pertaining to dismissals, acquittals, convictions, sentences, correctional supervision information and

information concerning the status of my parole or probation when applicable. Further, I understand that the information

may include similar information obtained from other local, state and federal criminal justice agencies and may include

information pertaining to convicted person data, outstanding arrest warrants, missing persons and current and/or prior

gaming and non-gaming sheriff’s work cards that were issued to me.

2. I understand that I may review and challenge the accuracy of any and all criminal history records which are returned to

the BOARD.

3. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State of

Nevada, the Nevada State Contractors Board, its officer(s), agent(s) and/or employee(s) who conducted my criminal

history records search and provided information to the BOARD for any statement(s), omission(s), or infringement(s)

upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons,

firms, institutions or agencies providing such information to the State of Nevada and the BOARD on the basis of their

disclosures. I have signed this release voluntarily and of my own free will.

4. In giving the above authorization, I understand that all information provided to the BOARD may be reviewed by the

BOARD or any other employee within the BOARD’S organization deemed necessary to make an informed decision.

This information is confidential, as relating to a third party beyond that of the BOARD and of the criminal justice

agencies in the performance of their official duties, and may not be further disseminated.

(Please initial) _________________

A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for all

purposes be as valid as the original.

PURSUANT TO NRS 199.120, I CERTIFY THAT I HAVE CAREFULLY REVIEWED THE INFORMATION CONTAINED IN

THIS DOCUMENT AND I ATTEST TO THE TRUTH AND ACCURACY OF THE INFORMATION CONTAINED IN THIS

BACKGROUND DISCLOSURE STATEMENT UNDER PENALTY OF PERJURY.

Applicant’s Name: ____________________________________ ________________________________________

(LAST, FIRST MIDDLE) (SIGNATURE)

Address: _______________________________________________________________________________________

Date:

To be Completed By Board Staff Only:

Submitted by: NEVADA STATE CONTRACTORS BOARD Date Submitted:

2310 CORPORATE DRIVE, SUITE 200

HENDERSON, NEVADA 89074

Agency’s Representative: __________________________________ ________________________________

(PRINT) (SIGNATURE)

Background Disclosure Statement & Authorization for Release of Information Page 3 of 3

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 15 of 26

FINGERPRINTING APPLICANTS/LICENSEES

Pursuant to the provisions of the Nevada Revised Statute (NRS) 624.265 and the Nevada Administrative Code

(NAC) 624.681, all applicants are required to submit their fingerprints for the purpose of conducting a criminal

background check.

Applicants may submit their fingerprints electronically via Live Scan technology, through an authorized vendor in

Nevada or through the submission of hard copy fingerprint cards, completed by a law enforcement agency.

Your application package includes a Fingerprint Verification for the Live Scan technology and a Background

authorization form which must be completed and submitted with your application. You may request hard copy fingerprint

submission cards from the Board if you elect to submit manual fingerprints.

Live Scan fingerprints will take approximately 1 month for the Board to receive a report and hard copy

fingerprints generally can take several months before a report is returned.

1. To have your fingerprints taken by an authorized vendor or a law enforcement agency, you must produce proof

of identity with photo identity documentation.

2. A list of authorized vendors in the State of Nevada is available at:

http://nvrepository.state.nv.us/Fingerprint/forms/fingerprint_sites.pdf

3. Electronic Submittal

– The Live Scan vendor will collect the required fees. The vendor will stamp and date the

verification form. You must bring the completed verification form and background authorization form to the NSCB.

Electronic submittal is provided by Nevada vendors only.

4. Hard copy cards

– The law enforcement agency will take your fingerprints on one (1) fingerprint card. You will

need to submit the fingerprint card with the completed authorization form to the NSCB. You must provide a

cashier’s check o

r money order in the amount of $

40.00 made payable to the Nevada Dept. of Public Safety.

Personal Checks,

Company Checks or Cash w

ill not be accepted.

5. For questions regarding this procedure, contact the Criminal Investigations Supervisor. For Reno, call 775-688-

1150 ext. 7884. For Henderson, call 702-486-1144.

Nevada State Contractors Board (Revised 9/14)

New License Application

Page 16 of 26

1(9$'$67$7(&2175$&7256%2$5'

2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150

Website: www.nscb.nv.gov



9HULILFDWLRQRI)LQJHUSULQWV6XEPLWWHG

The fingerprints of the named applicant have been taken and forwarded electronically to the Nevada Central Repository:

All applicants are responsible for all fees related to background investigations.

Name (Last, First, Middle)_________________________________________________

Date of Birth (mo/day/year)________________________________________________

Social Security Number___________________________________________________

Home Address (street)____________________________________________________

City___________________________________________________________________



State_________________________________________________________________

Zip___________________________________________________________________

Telephone-( )________________________________________________________

Cell-( )___________________________ E-mail______________________________



%\WKLVVLJQDWXUH,DXWKRUL]HP\ILQJHUSULQWVWREHVXEPLWWHGWRWKH1HYDGD&ULPLQDO+LVWRU\5HSRVLWRU\DQGWKH

)HGHUDO%XUHDXRI,QYHVWLJDWLRQIRUDFULPLQDOEDFNJURXQGUHSRUW

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______________________________________ ___________________________

Signature Date

--------------------------------------------------------------------------------------------------------------------------------------------

For office Use Only

Date Print Submitted: ___________________

Processed by:_________________________



All applicants are responsible for all fees related to livescan submittals.

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 17 of 26

NEVADA STATE CONTRACTORS BOARD

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (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

CHILD SUPPORT INFORMATION STATEMENT

(TO BE COMPLETED BY SOLE PROPRIETORSHIP APPLICANTS ONLY)

In compliance with State and Federal law, applicants applying for licensure as a sole proprietorship are required

to complete and submit this Child Support Information Statement with their application for contractor’s license.

Please mark the appropriate response and provide all other information requested on the form.

 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 a m in com pliance with a p lan approved by the Dist rict 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 pu blic agency enforcing the order to determine the actions

that you may take to satisfy the Order.

I certify, under penalty of perjury to the truth and accuracy of all statements contained herein.

____________________________

(Signature)

__________________________________________

(Print Name)

__________________________________________

(Social Security Number)

DATED this ___________ day of ____________________, _________

CHILD SUPPORT INFORMATION STATEMENT

(TO BE COMPLETED BY SOLE PROPRIETORSHIP APPLICANTS ONLY)

Nevada State Contractors Board Revised 9/14

New License Application

CLASSIFICATION OF CONTRACTORS (

A SEPARATE APPLICATION IS REQUIRED FOR EACH PRIMARY CLASSIFICATION)

PRIMARY CLASSIFICATION A - GENERAL ENGINEERING

SUBCLASSIFICATIONS

A1 .............................................................................................. AIRPORTS

A2 ............................................................................................. HIGHWAYS

A3 ..................................................................... DAMS AND RESERVOIRS

A4 ................................................................................................ BRIDGES

A5 ........................................................... DIAMOND AND CORE DRILLING

A6 ......................... DRILLING OF OIL, GAS AND EXPLORATORY WELLS

A7 ................................................................ EXCAVATING AND GRADING

A8 .... SEALING AND STRIPING OF IMPERMEABLE PAVING SURFACES

A9 .................................................................. PIERS AND FOUNDATIONS

A10 .........................................COMMERCIAL AND RESIDENTIAL POOLS

A10A ....................................................................... RESIDENTIAL POOLS

A10B .......................................................................... RESIDENTIAL SPAS

A10C ........................................................ REPAIR OF POOLS AND SPAS

A10D ............................................... POOLS AND SPAS OF FIBERGLASS

A10E ..................... MAINTENANCE AND REPAIR OF POOLS AND SPAS

A10F..WATER AND GAS LINES FOR RESIDENTIAL POOLS AND SPAS

A11 ........................................................................RECYCLING ASPHALT

A12................ EXCAVATING, GRADING, TRENCHING AND SURFACING

A13 ...................................................................... WRECKING BUILDINGS

A14 .......................... STEEL ERECTION AND INDUSTRIAL MACHINERY

A15 ........................................................... SEWERS, DRAINS AND PIPES

A16 .............. PAVING OF STREETS, DRIVEWAYS AND PARKING LOTS

A17 .................................................. LINES TO TRANSMIT ELECTRICITY

A18 .............................................................................. FARM IRRIGATION

A19 .................................................................. PIPELINE AND CONDUITS

A19A ............................................................................................ WATER

A19B ................................................................................................. GAS

A19C

...... ELECTRICAL CONDUITS FOR UNDERGROUND TRANSMISSION

A20 ........................................................................... INDUSTRIAL PIPING

A21 ............................................................. FENCING AND GUARDRAILS

A22 .................................................................................... UNCLASSIFIED

A23 .................................................................. REMOVAL OF ASBESTOS

A24 .................................. FOUNTAINS AND OTHER WATER FEATURES

A25 ..................................................... TELECOMMUNICATION TOWERS

PRIMARY CLASSIFICATION AB - GENERAL ENGINEERING AND GENERAL BUILDING

PRIMARY CLASSIFICATION B - GENERAL BUILDING

SUBCLASSIFICATIONS

B1 ......................................................... PREMANUFACTURED HOUSING

B2 .......................................... RESIDENTIAL AND SMALL COMMERCIAL

B3 ………………………………………………….SPECULATIVE BUILDING

B4… ......................................................................... SERVICE STATIONS

B5 ........................................... PREFABRICATED STEEL STRUCTURES

PRIMARY CLASSIFICATION C1 - PLUMBING AND HEATING

SUBCLASSIFICATIONS

C1A ............................................................................................. BOILERS

C1B ............................................................................. FIRE SPRINKLERS

C1C ................................................ INSULATION OF PIPES AND DUCTS

C1D .......................................................................................... PLUMBING

C1E .................................................................................... SHEET METAL

C1F ................................... HEATING COOLING AND CIRCULATING AI

R

C1G ............................................................. PIPES AND VENTS FOR GAS

C1H ............................................................................... WATER HEATERS

C1I ..................................................................... CHILLED WATER PIPING

C1J... SYSTEMS TO REPLENISH BREATHING AIR FOR FIREFIGHTERS

C1K ........................................................................... INDUSTRIAL PIPING

PRIMARY CLASSIFICATION C2 - ELECTRICAL

SUBCLASSIFICATIONS

C2A ......................................................................... ELECTRICAL WIRING

C2B ..................................................................... INTEGRATED CEILINGS

C2C ................................................................................ FIRE DETECTION

C2D ....................................................................................LOW VOLTAGE

C2E .................................................. LINES TO TRANSMIT ELECTRICITY

C2F ........................................................................ RESIDENTIAL WIRING

C2G…………………………………………………………..PHOTOVOLTAICS

PRIMARY CLASSIFICATION C3

–

CARPENTRY, MAINTENANCE AND MINOR REPAIRS

SUBCLASSIFICATIONS

C3A ............................................................. CARPENTRY AND REPAIRS

C3B .......................................................................... FINISH CARPENTRY

C3C ............................................. INSULATION & WEATHER STRIPPING

C3D ............................................................................ OVERHEAD DOORS

C3E…………………………………………………………………….DRYWALL

PRIMARY CLASSIFICATION C4 - PAINTING AND DECORATING

SUBCLASSIFICATIONS

C4A ............................................................................................ PAINTING

C4B ................................................................................ WALLCOVERING

C4C .................................................................... TAPING AND FINISHING

C4D ................................................................................. SANDBLASTING

C4E ........................................................................................... DRYWALL

C4F ....................................................................... SHEET METAL STUDS

C4G ............................................................................. ACOUSTICAL TILE

PRIMARY CLASSIFICATION C5

–

CONCRETE CONTRACTING

PRIMARY CLASSIFICATION C6 - ERECTING SIGNS

SUBCLASSIFICATIONS

C6A………………………………………………… OUTDOOR ADVERTISING

C6B…. ....................................................................... ELECTRICAL SIGNS

C6C .................................................................................... SHEET METAL

C6D................................................................................. PAINTED SIGNS

PRIMARY CLASSIFICATION C7 - ELEVATION AND CONVEYANCE

SUBCLASSIFICATIONS

C7A…. .................................................... ELEVATOR AND DUMBWAITER

C7B…. ..................................................... ESCALATOR AND CONVEYOR

C7C .............................................................................. PNEUMATIC TUBE

C7D............................................................................ MOVING WALKWAY

PRIMARY CLASSIFICATION C8 - GLASS AND GLAZING

PRIMARY CLASSIFICATION C9 - MOVEMENT OF BUILDINGS

PRIMARY CLASSIFICATION C10 - LANDSCAPE CONTRACTING

PRIMARY CLASSIFICATION C11 - SPRAYING MIXTURES CONTAINING CEMENT

PRIMARY CLASSIFICATION C13 - USING SHEET METAL

PRIMARY CLASSIFICATION C14 - STEEL REINFORCING AND ERECTION

SUBCLASSIFICATIONS

C14

A

..................................................................... REINFORCING STEEL

C14B ...................................................................... STRUCTURAL STEEL

C14C ..................................................................... ORNAMENTAL METAL

C14D .............................................................................. CURTAIN WALLS

C14E ..................................................... METAL DOORS AND WINDOWS

C14F............................................................................... STORE FRONTS

C14G ....................................... PREFABRICATED STEEL STRUCTURES

C14H ............................................................... AWNINGS AND LOUVRES

C14I .................................................................... RIGGING AND CRANES

C14J .............................................................. CONVEYANCE OF GOODS

PRIMARY CLASSIFICATION C15 - ROOFING AND SIDING

SUBCLASSIFICATIONS

C15

A

.......................................................................................... ROOFING

C15B .............................................................................................. SIDING

C15C..................................................................................... INSULATION

C15D........................................................................... WATERPROOFING

PRIMARY CLASSIFICATION C16 - FINISHING FLOORS

SUBCLASSIFICATIONS

C16A ........................................................................ COVERING FLOORS

C16B .................................................................... FINISHING COUNTERS

C16C .................................................... PLASTIC TILE AND WALLBOARD

PRIMARY CLASSIFICATION C17 - LATHING AND PLASTERING

SUBCLASSIFICATIONS

C17A… ........................................................................................ LATHING

C17B… ................................................................................. PLASTERING

C17C ......................................................................................... DRYWALL

C17D ............................................................................ ACOUSTICAL TILE

C17E .......................................... COATINGS OF STUCCO AND CEMENT

C17F............................................................... STUDS OF SHEET METAL

PRIMARY CLASSIFICATION C18

–

MASONRY

PRIMARY CLASSIFICATION C19 - INSTALLING TERRAZZO AND MARBLE

SUBCLASSIFICATIONS

C19

A

....................................................................................... TERRAZZO

C19B ............................................................................................ MARBLE

C19C..............................................ARTIFICIAL OR CULTURED MARBLE

PRIMARY CLASSIFICATIONS C20 - TILING

SUBCLASSIFICATIONS

C20A…. ................................................ PLASTIC TILE AND WALLBOARD

C20B…. ........................................ SWIMMING POOL TILE AND COPING

PRIMARY CLASSIFICATION C21 - REFRIGERATION AND AIR CONDITIONING

SUBCLASSIFICATIONS

C21

A

.............................................................................. REFRIGERATION

C21B .......................................................................... AIR CONDITIONING

C21C ................................................................................... SHEET METAL

C21D ..................................................................................MAINTENANCE

C21E ............................................................. SOLAR AIR CONDITIONING

C21F ........................................... CHILLED AND HOT WATER SYSTEMS

C21G ........................................................................ INDUSTRIAL PIPING

PRIMARY CLASSIFICATION C23 - DRILLING WELLS AND INSTALLING PUMPS, PRESSURE TANKS & STORAGE TANKS

PRIMARY CLASSIFICATION C24 - ERECTING SCAFFOLDS AND BLEACHERS

PRIMARY CLASSIFICATION C25 - FENCING AND EQUIPPING PLAYGROUNDS

PRIMARY CLASSIFICATION C26 - INSTITUTIONAL CONTRACTING

SUBCLASSIFICATIONS

C26

A

................................... KITCHEN AND LABORATOR

Y

EQUIPMENT

C26B ............................... BUILDING ACCESSORIES AND SPECIALTIES

C26C............................................................. FLOORS OF GYMNASIUMS

PRIMARY CLASSIFICATION C27 - INDIVIDUAL SEWERAGE

PRIMARY CLASSIFICATION C28 - FABRICATING TANKS

SUBCLASSIFICATIONS

C28

A

...................................................................... FABRICATING TANKS

C28B................................................... SANDBL

A

STING AND COATINGS

PRIMARY CLASSIFICATION C30 - INSTALLING EQUIPMENT TO TREAT WATER

PRIMARY CLASSIFICATION C31 - WRECKING

PRIMARY CLASSIFICATION C33 - INSTALLING INDUSTRIAL MACHINERY

PRIMARY CLASSIFICATIONS C36 - INSTALLING URETHANE

PRIMARY CLASSIFICATION C37 - SOLAR CONTRACTING

SUBCLASSIFICATIONS

C37

A

............................................................................. WATER HEATING

C37B .............................................................................. SPACE HEATING

C37C.......................................................................... AIR CONDITIONING

C37D........................................................................ HEATING OF POOLS

PRIMARY CLASSIFICATION C38 - INSTALLING EQUIPMENT USED WITH LIQUEFIED PETROLEUM AND NATURAL GAS

SUBCLASSIFICATIONS

C38A…. ....................................................................... PIPES AND VENTS

C38B…. ......................................... GAS APPLIANCES AND EQUIPMENT

C38C…. ..................................................... HEATING AND VENTILATING

PRIMARY CLASSIFICATION C39 - INSTALLING HEATERS

PRIMARY CLASSIFICATION C40 - SPECIALTIES NOT AUTHORIZED BY OTHER CLASSIFICATIONS

PRIMARY CLASSIFICATION C41 - FIRE PROTECTION

SUBCLASSIFICATIONS

C41

A

..................................................... AUTOMATIC FIRE SPRINKLERS

C41B ........................................ FIXED FIRE EXTINGUISHING SYSTEMS

C41C.................................................................................... FIRE ALARMS

C41D............................................................... PRIVATE FIRE HYDRANTS

PRIMARY CLASSIFICATION C42 - CONSTRUCTING, ALTERING, OR IMPROVING VIDEO SERVICE NETWORKS

E-1 OWNER/BUILDER NOT TO EXCEED THREE STORIES

E-2 OWNER/BUILDER EXCEEDING THREE STORIES

A COMPLETE DESCRIPTION OF EACH CLASSIFICATION CAN BE FOUND ON OUR WEB SITE: www.nscb.nv.gov

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 20 of 26

NEVADA STATE CONTRACTORS BOARD

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (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

OUT - OF - STATE LICENSE VERIFICATION FORM

THIS FORM MUST BE COMPLETED WHEN APPLYING FOR EXAM WAIVER BASED ON RECIPROCITY WITH

ARIZONA, CALIFORNIA, OR UTAH

Applicant Name________________________________

Company Name________________________________

Street Address_________________________________

City__________________________________________

State

Zip _________________

I am requesting licensure in the State of Nevada as a .

I am/have been licensed in the State of

issued under the company name of

_______________________________________________. My Social Security # is

.

I authorize you to release, to the State of Nevada, all information pertaining to license number: .

_______________________________________ ___________________________________________

Print Name of Applicant Signature of Applicant

NOTE TO APPLICANT: COMPLETE A SEPARATE FORM FOR EACH LICENSE NUMBER

TO VERIFYING STATE: Please furnish the information requested. Sign and verify the document. Place the

completed form in an envelope, seal the envelope, and provide it to the applicant either in person or by mail.

Company Name ____________________________________________________________________________

Type of License (Classification) _________________________________________________________________

Original Date of Issue

License Number________________

Amount of Limit (If any)

Amount of Bond (If any)______________________

Any record of suspensions, revocations, other disciplinary actions, or current Complaints?_________

, If yes, please provide a copy of

the action.

Current Status of License: ________________

If not Active, Reason: ___________________________

Name of Qualifying Individual & Title ______________________________________________________________

Licensed by:

 Waiver of Exam (Basis of Waiver): _____________________________________________

 Successful Completion of Exam - Specify Type:_________________________________________

 Endorsement from the State of: _________________________________________

Other Personnel Listed & Titles_________________________________________________________________

AGENCY SEAL SIGNATURE TITLE _________________________

INSTRUCTION TO APPLICANT

Insert your name and a ddress and comp lete the top

portion of thi s request. Give the form to the

appropriate agency. The verifying agency will mail the

completed verification to you at the address you have

listed. Include the completed form with

your

application.

Additional Forms available at www.nscb.nv.gov

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 21 of 26

NEVADA STATE CONTRACTORS BOARD

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (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

BANK VERIFICATION FORM

Name of Licensee/Applicant: _____________________________________________

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

A

ccount Name Account Numbe

r

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

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: __________________________

Red bordered fields are required.

Nevada State Contractors Board

New License Application (Revised 9/14)

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NEVADA STATE CONTRACTORS BOARD

9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (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

REFERENCE CERTIFICATE

TO THE CERTIFIER: You must hav e direct knowledge of this individual’s experience, and be able to certify that he or she has

demonstrated a level of kn owledge and skill e xpected of a journeyman or better. Jou rneyman is d efined as a person who is fu lly

qualified to perform, without supervision, work in the classification for which he or she is applying, or has successfully completed a

program of a pprenticeship approved by the state apprenticeship council, or an equivalent program accepted by the Board. All

portions of this form must be completed.

I certify that I have personally known ___________________________________________, and that I have direct knowledge of

(print name of individual you are completing reference for)

his / her experience that I have listed below

DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED BY THIS INDIVIDUAL AT THE LEVEL OF

JOURNEYMAN OR BETTER. LIST SPECIFIC TRADES AND DUTIES.

PLEASE TYPE OR PRINT IN INK

________________________________________________________________________________

The above-stated work was performed from _______ / ________ / ________ to _______ / ________ / _______

 Full-time  Part-time (If part-time specify aggregate total ___________ yrs _________ mos.)

Check the box that identifies the level that this individual worked at while performing the trade(s) or craft(s) listed above.

 Journeyman  Foreman  Supervisor  Contractor

Check the box that identifies your business relationship to this individual, at the time the experience was gained by them.

 Employer  Union Representative  Building Inspector  Engineer  Architect  Contractor

 Supervisor  Other, specify relationship ________________________

IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it

is suggested that you keep a copy of the certificate(s) you have completed.

I certify under penalty of perjury to the truth and accuracy of the statements and information contained herein.

___________________________________________ Number: _________________________ State: ________

(Signature of the Certifier If you are a licensed/registered contractor, enter your license/registration

number and state)

________________________________________________ _________________________________________________________

(Print name) (Company or business you are affiliated with)

________________________________________________________________________________________

(Address – City – State – Zip)

(______)___________________________________ (_____)________________________ ______________________________________

(Daytime Telephone Number) (Fax Number) (Email Address)

This Certificate Must be Notarized

Subscribed and sworn to before me this _____ day of ___________, _________

___________________________________________Notary Public in and for County of ___________ State of ________

Nevada State Contractors Board

New License Application (Revised 9/14)

Page 23 of 26