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2. DEPT. OF BUSINESS &  

   PROFESSIONAL REGULATION (DBPR) LICENSED CONTRACTOR 

   REGISTRATION

4. CITY OF KEY WEST

   BUILDING DEPARTMENT

   P.O. BOX 1409

   KEY WEST, FL  33040

8. Date:*
   Date:
10. Business Name:*
12. Qualifier Name:*
14. Business Address:*
16. City*
17. State*
18. Zip Code*
20. Business Phone Number:*
21. Mobile Number:*
23. E-mail: *
25. Select which applies:*

    1. Air Conditioning
    2. Alarm Systems
    3. Asbestos
    4. Building
    5. Electrical

    1. Electrical Speciality
    2. Elevator
    3. General Contractor
    4. Mechanical
    5. Mold Remdiator

    1. Plumbing
    2. Pollutant Storage
    3. Pool / Spa
    4. Residential
    5. Roofing

    1. Sheet Metal
    2. Solar
    3. Utility / Excavate
    4. Speciality
27. Attached either Workers' Comp (WC) Insurance or WC Exemption:*
28. Attach Copies of Business Tax Receipts from Local Jurisdiction: *
29. Attach Copies of Liability Insurance:*
30. Attach Copies of DBPR State License *
32. Electronic Signature*

    By checking "I agree", you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.

    1. I agree
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

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