PERMIT PAGE ONLINE APPLICATION FOR LICENSE REGISTRATION
Please print or type - Need Copy of Drivers License and all Plumbing, Backflow or Electrical Licenses
Contractor InformationDate: __ __ / __ __ / __ __ __ __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: (__ __ __) - __ __ __ - __ __ __ __
_____ Do you want to use Company information for mail address?
Company Information Company Name: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Contractor Address: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __City: __ __ __ __ __ __ __ __ __ __ __ State: Texas Zip: __ __ __ __ __ - __ __ __ __ Phone: (__ __ __) - __ __ __ - __ __ __ __ Phone: (__ __ __) - __ __ __ - __ __ __ __
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 ___________________
Additional Comments: _____________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
For Office use Only:CODE: __ __ __ __ __ __ __ __ __ __ __ __ Received on: __ __ / __ __ / __ __ __ __