B
OROUGH OF CONSHOHOCKEN
400 Fayette Street, Suite 200 Conshohocken, PA 19428
Phone (610) 828-1092 Fax (610) 828-0920
REGISTRATION FOR PLUMBERS: FEE: $75
☐ New Registration ☐ Renewal ☐ Update Only
Date of Application: __________________
Corporation or Firm Name: _______________________________________ PAHIC #: _____________
Applicants Name: _____________________________________________________________________
Applicant is 18 or older: ☐ Yes ☐ No. Applicant is a citizen of the United States: ☐ Yes ☐ No
Mailing Address: ______________________________________________________________________
City, State and Zip: _____________________________________________________________________
Phone #: _____________________ Fax #: _____________________ Cell # _____________________
E-Mail: _______________________________________________________________________________
Has your Registration or License been revoked by any municipality within the last 2 years?
☐ Yes ☐ No
Have you any outstanding civil judgments pertaining to your work as a contractor?
☐ Yes ☐ No
I
F YOU ANSWERED “YES”: TO ANY QUESTIONS PLEASE ATTACH EXPLAINATION.
Liability Insurance Carrier: ______________________________________________________________
Policy #: _________________________________________ Expires: __________________________
Workman’s Compensation Carrier: _______________________________________________________
Policy #: _________________________________________ Expires: __________________________
Insurance Agent: _________________________________ Policy Period: _____________________
Phone #: _____________________ Fax #: _____________________
• The applicant must provide certificate of insurance, maintained at the expense of the applicant, as follows: no less
than $100,000 to $300,000 for bodily injury; no less than $100,000 for property damage, public liability, and products
liability; and at least $50,000 for completed operations, each of which shall have a single occurrence limit. Borough
of Conshohocken must be noted as HOLDER.
☐
I am a Contractor with no employees. The law prohibits Contractors, to employ any
individual to perform work, pursuant to this registration, unless Contractor provides proof of
Workers’ Compensation Insurance to the Borough.
T
HIS FORM MUST BE NOTARTIZED IF CHECKED BOX ABOVE.
I cer
tify that the statement(s) contained herein are true and correct to the best of my knowledge
and belief. I understand that if I knowingly make any false statement herein, I am subject to
such penalties as may be prescribed by law or ordinance.
Applicant’s Signature:
______________________________________________
My Commission Expires: ___________
400 Fayette Street, Suite 200 | Conshohocken, PA 19428|Phone: (610) 828-1092|Fax: (610) 828- 0920|www.conshohockenpa.org
For office use only LICENSE #: ____________________
ID Provided: _________________ (copy) Paid: ☐Yes ☐ No
Confirmed with Attorney Generals Office: ☐Yes ☐ No
Complaints with Attorney Generals Office/BBB: ☐Yes ☐ No
Complaints from BOC: ☐Yes ☐ No
Insurance Certificate Attached: ☐Yes ☐ No
Completed By:_______________
Date Completed:_______________
NOTARY
(seal)
