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(Please Print Clearly) Name of Applicant: Name & Address of Company: Telephone Number: Email Address: Type of Contractor General Mechanical Plumbing State License Number Electrical Date Passed Electrical Exam Insurance PROVIDE YOUR CERTIFICATE OF LIABILITY TO OUR OFFICE Proof of Liability Insurance Company Name: Address: Phone Workmen’s Compensation Insurance Company Name: Address: Phone I have received a copy of Ordinance#12-17-90-A and agree to abide by the provisions of this ordinance. Signature of applicant: Issued On: Signature of Building Commissioner of Brown County or Authorized Representative Due to budget cuts: Please enclose a self addressed stamped envelope for your receipt and contractors ID card. Thank You for your assistance. BROWN COUNTY GOVERNMENT BUILDING DEPARTMENT 201 Locust Lane Phone: (812) 988-5490 P.O. Box 401 Fax: (812) 988-5488 Nashville, Indiana 47448 www.browncounty-in.gov OFFICE USE ONLY Date: License Receipt Fee $ 35 ( ) Check ( ) Cash