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CONTRACTOR REGISTRATION FORM CITY OF MIDLAND – BUILDING DEPARTMENT 333 W. ELLSWORTH ST., MIDLAND, MI 48640 [PHONE REDACTED] Email: [EMAIL REDACTED] THE FOLLOWING INFORMATION IS REQUIRED BY PUBLIC ACT 230 OF 1972 FOR ALL PERMIT APPLICATIONS FOR WORK ON RESIDENTIAL BUILDINGS OR STRUCTURES. THE CITY OF MIDLAND ALSO REQUIRES A COPY OF YOUR CURRENT CONTRACTORS LICENSE AND A $15 ADMINISTRATIVE FEE (PAYABLE TO THE CITY OF MIDLAND) FOR REGISTRATION. COMPANY NAME ADDRESS PHONE # EMAIL ADDRESS STATE LICENSE # EXP. DATE FEDERAL EMP ID # REASON FOR EXEMPTION FROM SECTION 6109 OF IRS CODE: MESC EMP # REASON FOR EXEMPTION FROM MRSC ACT 1936 (ExSess) PA1, MCL 421.1 TO 421.75: INSURANCE CARRIER REASON FOR EXEMPTION FROM WORKERS DISABILITY ACT OF 1969, 1969 A 317 MCL418.101 TO 418.941: A COPY OF YOUR CURRENT CONTRACTORS LICENSE AND A $15 ADMINISTRATION FEE MUST BE INCLUDED. Rev 4/30/13