Town of Loxahatchee Groves
155 F Rd. • Loxahatchee Groves. FL 33470 • (561) 793-2418 • Fax (56 1) 793-2420 • www.loxahatchceegrovesfl.gov
CONTRACTORS APPLICATION FOR
REGISTRATION FEE $2.00
Date: ___________________________________________________________________________________________
Name of Business: ________________________________________________________________________________
Address of Business: _______________________________________________________________________________
Mailing Address: _______________________________________ Email: ____________________________________
Business Phone: _______________________________________ Emergency Phone: __________________________
Owner’s Name: ___________________________________________________________________________________
THE FOLLOWING DOCUMENTS MUST BE SUMITTED IN ORDER TO ISSUE THE BUSINESS TAX RECEIPT:
COUNTY BUSINESS TAX RECEPIT:
County or County-Wide Business Tax Receipt (If Applicable). Please Note: Any holder of a County-Wide
Business Tax may purchase a Town Business Tax Receipt for $2.00. All Others will pay the full fee.
CERTIFICATE OF INSURANCE:
Certificates of Insurance (Liability and Worker’s Compensation) issued to the Town of Loxahatchee Groves.
ARTICLES OF INCORPORATION:
First Page of Articles of Incorporation, Corporate Seal or Copy of Fictitious Name (Found on Sunbiz).
CERTIFICATE OF COMPETENCY OR STATE LICENSE:
(Please check one and place License# inside box)
The following is a list of Contractors who are required by Florida Law, Chapter 85-278, to have a State License.
UNDERGROUND UTIL. CONTRACTOR
QUALIFIER INFORMATION
SIGNATURE MUST BE NOTARIZED IF THIS DOCUMENT IS PRESENTED
BY SOMEONE OTHER THAN THE QUALIFIER.
STATE LICENSE NUMBER OR COUNTY TAX RECEIPT NUMBER
NAME ________________________________________________ TITLE ____________________________________
ADDRESS _______________________________________________________________________________________
TAX ID#__________________ DATE OF BIRTH ________________ DRIVERS LICENSE#_____________________
PHONE ____________________________________ EMERGENCY PHONE __________________________________
__________________________________________
QUALIFIER’S SIGNATURE
click to sign
signature
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