Acton Municipal Utility District

PERMIT PAGE     ONLINE APPLICATION FOR LICENSE REGISTRATION

Please print or type  - Need Copy of Drivers License and all Plumbing, Backflow or Electrical Licenses

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Contractor Information

Date: __ __ / __ __ / __ __ __ __

Contractor License: LI __ __ __ __ __ __ __ __ __ __ __     Expires on:  __ __ / __ __ / __ __ __ __

We will need a copy of Plumbers license or Irrigators license to establish Contractor as a viable provider.

 

Contractor Last Name:  __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Contractor First Name:  __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

Contractor Middle Initial:  __ 

 

Contractor Address: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City:  __ __ __ __ __ __ __ __ __ __ __  State:  Texas     Zip:  __ __ __ __ __ - __ __ __ __

 

Phone:  (__ __ __) - __ __ __ - __ __ __ __     Phone:  (__ __ __) - __ __ __ - __ __ __ __

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_____  Do you want to use Company information for mail address?

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Company Information

 

Company Name:  __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

 

Contractor Address: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City:  __ __ __ __ __ __ __ __ __ __ __  State:  Texas     Zip:  __ __ __ __ __ - __ __ __ __

 

Phone:  (__ __ __) - __ __ __ - __ __ __ __     Phone:  (__ __ __) - __ __ __ - __ __ __ __

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Fill in all that apply:

License Number                                                        Expires On                                                License Type

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      BP  Backflow Tester

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      LI   Irrigator

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __            CSI Inspector

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      J     Journeyman Plumber

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      JE    Journeyman Electrician

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      M    Master Plumber

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __      ME   Master Electrician

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __             Other ___________________

__ __ __ __ __ __ __ __ __ __ __      __ __ / __ __ / __ __ __ __             Other ___________________

 

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Additional Comments:  ________________________________________________________________

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For Office use Only:

CODE:  __ __ __ __ __ __ __ __ __ __ __ __     Received on:  __ __ / __ __ / __ __ __ __  

 

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Copyright © 2004-2007 Acton Municipal Utility District
Last modified: June 28, 2010