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3/6/12 CONTRACTOR’S LICENSE RENEWAL APPLICATION City of Douglas-Planning Department P. O. Box 1030/101 N. 4th Street Douglas, Wyoming 82633-1030 (307) 358-2132—Fax (307) 358-2133 Application for license shall be made to the Planning and Community Development Department. Business name: Applicant’s name: Mailing address: City: State: Zip code E-mail Address : We need this to send information to you throughout the year. Telephone number: ( ) Alternate # ( ) Licenses are renewed on January 1 of each year. If your license has lapsed for more than 60 days you will need to apply for a new license and meet all the requirements for a new license. Please give a detailed description of services offered: (This must be filled out completely) Type of license sought (Check all types that apply) General Contractor ($100.00) Building Contractor ($100.00) Residential Contractor ($100.00) M-Plumber w/gas piping ($25.00) J-Plumber w/gas piping ($25.00) R-Plumber w/gas piping ($25.00) Apprentice Plumber ($15.00) M-Gas Pipe Fitter ($25.00) M-HVAC ($25.00) J-HVAC ($25.00) Apprentice HVAC ($15.00) Concrete (Structural) ($25.00) Concrete (Non-Structural ($25.00) General Roof ($25.00) Shingle Roof ($25.00) Electrical ($25.00) Exterior Finish ($25.00) Interior Finish ($25.00) Low Voltage ($25.00) Landscaping ($25.00) Arborist ($25.00) Grading/Utilities ($25.00) Outside Utilities Contractor ($25.00) Sewer/Drain Maintenance ($25.00) Demolition ($25.00) Framing ($25.00) Other ($25.00) Refrigeration contractors must provide a copy of Federal refrigeration certification; Certification Number . Electrical contractors must provide a copy of current State of Wyoming Electrical License; License number . This information is true and accurate to the best of my knowledge. Any false or misleading information will result in suspension or revocation of license. Applicants printed name: Date: Signature of Applicant: ---PAGE BREAK--- Page 2 of 2 For Office Use Only Fee: Date: Receipt License # Date Issued: Proof of Liability Insurance Amount Proof of State license attached Yes___ No___ Date Approved: Approved by