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® Pasco County Building Construction Services <br /> Contractor Licensing <br /> xs <br /> ..; . 8731 Citizens Drive, Suite 230 <br /> �+ i New Port Richey, FL 34654 1 MA <br /> (727)847-8009 <br /> ` contractorlicensing@r)ascocountyfl.net <br /> r � <br /> State Certified Contractor Maintenance Form <br /> Please upload or mail this form along with the items listed below. <br /> The following information is required: G�/ <br /> 1. Copy of the State Certified Contractor's License. State License No. _� <br /> 2. A copy of the Workers' Compensation Certificate. Certificate must indicate Pasco County as the <br /> certificate holder. It must indicate the name of the business entity, indicating the license holder is <br /> covered under the Workers' Compensation Policy. <br /> "OR" <br /> A copy of the license holder's Workers' Compensation Exemption Card. <br /> 3. The license holder's current home, business address, and phone numbers. <br /> Home Address: Business Name &Address: <br /> I 05-U-3 Ph IGX G I ccll e f . j -a <br /> �\n an G SosScA, L 01 G &A <br /> q '(�Q o <br /> Personal Phone: 3 ` "I — I I;o Business Phone: i513-2 S- 92u7 <br /> 4. Year of Birth of the License Holder: I CN o <br /> 5. Email Address: 6 iSpG,4Ch Q QGASc4aL.,UQ,-� <br /> 6. Space below is for Authorized Signer(s) to record license, sign for, and obtain permits. This form <br /> supersedes all other letters and forms. 1,� I/ <br /> Person: I�1 Gt�/(� bj r,t 0I�I n Person: Ill 1?1 A- 'A W Qst V r 00 K <br /> Person: I CV ) \S 1 Z-2 C Person: G a S-e l/ s► f <br /> Person: ' S ) Person: M��i n�a �(���CAX <br /> Authorized individuals will remain in full force and effect until written documentation i ubmitted, withdrawing <br /> the authorization. The license holder is responsible to keep all information current a correct. <br /> License Holder: &\-6 C1Y0,,kZ License Holder Signature: <br /> (Print Name) <br /> Please Note: Notary section below needs to be completed. <br /> State of Florida <br /> County of Pasco <br /> Sworn to and subscribed before this day l� O <br /> -NotkyPublic State of Florida <br /> (Stamp) <br /> My commission expires O? dg I ti. <br /> b of Fbrida <br /> c�/devsvcsdocuments/1-documentspecialists/bcs/bcsforrns/State Certified ContractorRim <br /> ar Revised 8/19/16 <br /> FF 997138 <br /> 19 <br />