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CITY OF CODY MASTER ELECTRICAL CONTRACTOR LICENSE APPLICATION Applicant’s Name (Qualifier): Business Name: Physical Address: City: State: Zip: Mailing Address: City: State: Zip: Phone: Cell: Email: Please read the contractor licensing regulations, found in Title 9, Chapter 3 of the City of Cody Code (attached and/or available online at: www.cityofcody-wy.gov/111/Municipal-Code Wyoming Licenses: Provide a copy of your current Wyoming master electrician license and your electrical contractor’s license (card) issued by the State of Wyoming. Insurance: Provide an insurance certificate from your insurance company indicating that your company has liability insurance in the amounts noted below, and which insurance certificate lists the City of Cody as a “certificate holder” (not “additional insured”). □ Bodily injury liability insurance coverage of not less than one million dollars per person/occurrence; and, □ Property damage liability insurance coverage of not less than one million dollars for each occurrence. Fee: The application must be accompanied by the $150.00 application fee. Payment may be made to the City of Cody by cash, check, or credit card (Visa, MasterCard, Discover). Certification: By signing this application form, I certify that: 1) I have read and understand the City of Cody Contractor Licensing Ordinance (Title 9, Chapter 3 of the City of Cody code) and agree to comply with the requirements thereof; 2) The information contained in this contractor license application and associated documents submitted herewith is true and accurate; and, 3) I understand that failure by me, or my employees while under my supervision, to comply with the requirements of the City of Cody Contractor Licensing Ordinance, including failure to obtain all required permits and inspections, is grounds for suspension and revocation of my contractor license. Signed this day of , 20 . Name of Business: By: Title/Office: (Signature must be notarized—notary block on next page.) (OVER) STAFF USE Invoice: Date Submitted: ---PAGE BREAK--- STATE OF WYOMING ) ) COUNTY OF PARK ) The foregoing instrument was acknowledged before me by this day of , 20 . Witness my hand and official seal. Notary Public My Commission Expires: Office Use Only: □ Master Electrical Contractor license authorized this _ day of , 20 , by , Building Official.