Fillable STATE CERTIFIED CONTRACTOR

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STATE CERTIFIED CONTRACTOR

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APPLICATION FOR REGISTRATION INDIAN RIVER COUNTY/CITY OF VERO BEACH
STATE CERTIFIED CONTRACTOR
*NO FEE* APPLICATION DATE: ________________________________
TYPE OF CONTRACTOR: _______________________________________________________
BUSINESS NAME: _____________________________________________________________
QUALIFIER NAME: ____________________________________________________________
MAILING ADDRESS: ___________________________________________________________
PHYSICAL ADDRESS: __________________________________________________________
QUALIFIER DRIVER’S LICENSE STATE: ____________ DL #: ________________________
QUALIFIER D.O.B.: _________ BUSINESS E-MAIL: _________________________________
BUSINESS PHONE: _____________________ BUSINESS FAX: ________________________
BUSINESS MOBILE: _________________________
The following is REQUIRED to be submitted with this application in order for us to process the application.
Incomplete Applications will not be processed:
1. Copy of State Certificate.
2. Copy of Business Tax Receipt/Occupational License.
3. Certificate of Insurance for:
• General Liability
• Worker’s Compensation or State of Florida - Worker’s Compensation Exemption Certification.
Certificate Holder: Indian River County Building Department, 1801 27
th
Street, Vero Beach, FL 32960
4. Copy of Qualifiers Valid Driver’s License.
I hereby agree to keep the required insurance in force, and to procure a City of Vero Beach or Indian River County
Local Business Tax Receipt (Occupational License) prior to opening a place of business within these jurisdictions.
____________________________________ _____________________________________
QUALIFIER’S SIGNATURE QUALIFIER’S PRINTED NAME
STATE OF ____________________, COUNTY OF ________________________:
The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization
this _____ day of _______________, 20_______, By _____________________________________.
SEAL: NOTARY PUBLIC:
Personally Known: ______ Signed: ____________________________
Produced Identification: ______ Printed Name: _______________________
Type of Identification: _________
BUILDING DIVISION
CONTRACTOR LICENSING DEPARTMENT
772-226-1960
FAX #: 772-770-5333
INDIAN RIVER COUNTY/
CITY OF VERO BEACH
REGISTRATION PROCEDURES
STATE CERTIFIED APPLICANTS:
1. Complete Application fully (Put N/A in boxes that do not apply).
2. Submit a copy of current Florida State Certificate.
3. Provide Certificate of Insurance for:
• General Liability
• Worker’s Compensation
Certificate Holder: Indian River County Building Department, 1801 27
th
Street, Vero Beach, FL 32960
Note: If you’re exempt from Worker’s Compensation Insurance, please provide proof of exemption.
4. Submit copy of current business tax receipt/occupational license (municipality of business).
5. Submit copy of qualifier’s valid Driver’s License.
6. Completed Application(s) can be scanned and emailed in pdf format to ContractorLicensing@ircgov.com
C E R T I F I E D
THESE DOCUMENTS MAY BE EMAILED, MAILED, DELIVERED OR FAXED.
IF FAXED, PAYMENT CAN BE MADE WITH CHARGE CARD. COMPLETE THE FORM:
http://www.irccdd.com/Applications/Credit_Card/Application.pdf
To submit a completed application (pdf format) or for further information, contact the Contractor License
Department by email: contractorlicensing@ircgov.com
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STATE CERTIFIED CONTRACTOR

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Completed 22 January 2022

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