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5. State License #
6. Expiration Date
7. PCCLB #
8. Expiration Date
10. Business/Firm Name*
11. Business Phone Number
13. Email*
14. Business Location*
16. Mailing Address (if different than business location)
20. Please select one of the following options for receiving access to the online portal:

    1. Receive invite via email
    2. Receive invite via SMS text message
21. Printed Owner's Name - if different from qualifier
23. Cell #
24. Insurance Company Name (General Liability)
25. Insurance Company Name (worker comp)
27. Qualifying Agent's Signature*
    By typing your name here, you are signing this form electronically. You agree you are submitting this application for processing and is the legal equivalent of your manual signature on this form. You must be the legal qualifier which match our registration records. Note: A notarized Letter of Authorization is required for an agent to sign the application or any other correspondence that calls for an agent signature.
29. RETURN THIS APPLICATION WITH COPIES OF THE FOLLOWING DOCUMENTS:
31. Letter of Authorization (if applicable)
    Qualifier to authorize agents for permit drop-off/pickup, must be notarized
32. State License
33. PCCLB
    Pinellas County Certificate of Competency
35. *Certificate of Insurance

    General Liability ($100,00/$500,000 each occurrence)

36. *Certificate of Insurance*
    Workers Compensation or State-approved Exemption Certificate
38. *COI(s) with the City of Oldsmar listed as a certificate holder and addressed to 100 State St W, Oldsmar, FL 34677
40. Businesses operating from The City of Oldsmar g from The City of Oldsmar are required to obtain a local business tax receipt.
    Starting a business in Oldsmar

    Certificate of Competency, Business Tax Receipt, and Insurance Certificate must have the same business name.
42. Schedule inspections, check permit status and results, or make payments online for outstanding permit fees visit
    Online contractor portal
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field