Fillable REGISTRATION OF BUILDING AND REPAIR SERVICES (Dade County Georgia)

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REGISTRATION OF BUILDING AND REPAIR SERVICES (Dade County Georgia)

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The REGISTRATION OF BUILDING AND REPAIR SERVICES (Dade County Georgia) form is 2 pages long and contains:

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  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Dade County Georgia

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P a g e | 1
REGISTRATION OF BUILDING
AND REPAIR SERVICES
PERMIT APPLICATION
[Ordinance No. 05-01-11; O.C.G.A. § 38-3-56]
Application date: _____________________
Application fee: $35.00
Group/Organization: ___________________________________________________________________
Contractor’s Name: ___________________________________________________________________
Address: ________________________________________________
________________________________________________
Telephone: ________________________________________________
Mobile: ________________________________________________
Fax: ________________________________________________
Email: ________________________________________________
Federal Employer Identification Number: ______ - __________________________
OR
Applicant’s Social Security Number: _____________ - _______ - ______________
Georgia Sales Tax Number or Authorization: ______ - __________________________
If applicant is a corporation, list the state: _______________ and date of Incorporation: ____________
Tag registration information for each vehicle to be used in the business:
1. Tag Number: _____________ Vehicle Year, Make & Model: ____________________________
2. Tag Number: _____________ Vehicle Year, Make & Model: ____________________________
3. Tag Number: _____________ Vehicle Year, Make & Model: ____________________________
4. Tag Number: _____________ Vehicle Year, Make & Model: ____________________________
(use additional pages if necessary)
P a g e | 2
List of cities and/or counties where the applicant has conducted business within the past 12 months:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Georgia, County or City business license number: ____________________________________________
Is a copy of license from the Secretary of State available? Yes No
Proof of workers’ compensation insurance coverage as required under Georgia law: Yes No
An executed affidavit, in a form acceptable to the County, verifying compliance with the
Systematic Alien Verification for Entitlements (SAVE) Program or E-Verify (if no attach): Yes No
I, _______________________________________, (person applying) under oath, complete an
application for a registration of building and repair services permit in accordance with Dade County
Code of Ordinance No. 05-01-11 and O.C.G.A. § 38-3-56. Furthermore, I agree to indemnify and hold
harmless the government of Dade County, Georgia, its officers, department, constitutional officers,
employees and agents from liability of damages arising from any acts or omissions emanating from
issuance of this permit. This Subcontractor E-Verify Affidavit and/or Georgia Security and Immigration
Compliance Act shall be made a part of the application form. By executing this affidavit, the
undersigned contractor/subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of
services under a contract with _______________________________________ (name of business/corp.)
on behalf of the _______________________________________________________ (Owner/Contractor)
has registered with and is participating in a federal work authorization program to verify information of
newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L.
996031, in accordance with the applicability provisions and deadlines established in O.C.G.A. § 13-10-91
Authorized Signature: _______________________________________________ Date: _____________
PERMIT EXPIRES SIX MONTHS FROM DATE OF ISSUANCE
SUBSCRIBED AND SWORN BEFORE ME THIS
THE ________ DAY OF _________________ , 20___
___________________________________________
Notary Public
My Commission Expires: ______________________
For Office Use Only:
Date given to Applicant: _______________
Date received from Applicant: _______________
Application fee paid: Yes [ ] No [ ]
Declared Emergency or Disaster: Yes [ ] No [ ]
Not-for-Profit Group/Organization: Yes [ ] No [ ]
County Executive’s approval: _______________
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REGISTRATION OF BUILDING AND REPAIR SERVICES (Dade County Georgia)

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Completed 17 July 2020

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