CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY
Website:
2300 NORTH JOG ROAD, Ste. 2W-61
WEST PALM BEACH, FL 33411-2741 www.pbcgov.com/pzb/contractors E-mail:
PHONE: 561-233-5525 pzbccert@pbcgov.org
FAX #: 561-233-5554
INSTRUCTIONS FOR COMPLETING APPLICATION
THIS COMPLETE, ORIGINAL APPLICATION, ( NO FAXES ), INCLUDING CREDIT REPORTS, MUST BE IN OUR
OFFICE BY THE 1
ST
FRIDAY OF THE MONTH THAT YOU WANT THE BOARD TO CONSIDER YOUR
APPLICATION. THE APPLICATION WILL BE RETURNED IF NOT COMPLETE.
APPLICATION REVIEW IS HELD MONDAY THRU FRIDAY, BETWEEN 8:00 A.M. AND 11:30 A.M. ONLY.
Application is complete if it includes the following:
1.
APPLICABLE FEE - Payable to the Board of County Commissions of Palm Beach County by check or cash in the amount of
$450.00.
2.
PHOTO - 1 Recent Passport photo of applicant (MAXIMUM 2" x 2").
3.
A CLEAR COPY of a valid Driver's License or other Government issued ID.
4.
RESUME ' - must account for the years required for experience depending on requested trade.
5.
VERIFICATION OF EXPERIENCE -Complete affidavit of experience - experience must be verified by a licensed contractor; signature notarized, and copy of contractor's license and driver's license.
IF SELF-EMPLOYED - verification of required experience may be supplied from copies of past and current certificates of competency or licenses (if required) or original notarized letters from Building Officials or licensing agencies, AS WELL AS , A) copies of contracts with your signature and the customer's signature - one per month covering the required time period; OR if possible, B) notarized letters from contractors for whom you performed work as a sub-contractor (listing the time frame involved).
6.
FINANCIAL STATEMENT - List the name of company, cash (ending balance from current bank statement) and whatever you are using for company (i.e. truck, equipment, etc.) Sole Proprietorship - if in applicants name only (i.e. John Jones), fill in as a personal financial statement.
Net Worth Requirements:
General, Building, & Residential $20,000.00
Carpentry, Demolition, Electrical, HARV, Plumbing, Roofing, Structural Steel, Swimming Pool Construction
& Underground Utilities
Marine
All other Specialty Trades
$10,000.00
$5,000.00
$2,500.00
Net Worth shall be defined as having a minimum of 50% in cash verified by a current company bank statement or bank letter.
7.
CREDIT REPORT - Credit Reports (1) one on applicant and (1) one on company. If company is less than 6 months old (1) one for applicant and (1) one for each officer. Credit Reports must come from a nationally recognized credit agency and sent directly to our office.
8.
RECIPROCITY - If applying for Reciprocity - A letter of reciprocity is required from the County that licensed and sponsored your exam, with a minimum score of 75% on both the Trade and Business & Law (If an exam was taken prior to 1993, Business & Law had not been required, you will be required to take the Business & Law exam).

ONCE THE BOARD APPROVES YOUR APPLICATION FOR EXAMINATION, YOU WILL BE SENT A
REGISTRATION PACKET. YOU WILL THEN NEED TO SCHEDULE DIRECTLY WITH THE APPROVED
EXAMINATION COMPANY, AND YOU WILL NEED TO PAY THE TESTING AGENCY THEIR REQUIRED FEES. o
ONCE APPLICATION FOR RECIPROCITY HAS BEEN APPROVED BY THE BOARD, THE FOLLOWING
INFORMATION IS REQUIRED TO OBTAIN AN ACTIVE CERTIFICATE OF COMPETENCY. ALL DOCUMENTS BE
IN THE EXACT NAME LISTED ON YOUR APPLICATION AND LISTING PALM BEACH COUNTY AS
CERTIFICATE HOLDER. IF YOUR CERTIFICATE IS BEING ISSUED INACTIVE, YOUR CERTIFICATE WILL BE
SENT DIRECTLY TO YOU .
1.
General Liability Insurance on the firm in the minimum amounts of $100,000/$300,000 AND $10,000 Property Damage.
2.
Workers Compensation Insurance (If your company uses a Leasing Company, the certificate must show the qualifier being covered under the Policy as stated on certificate or accompanied by a roster) or Worker Compensation Exemption form from the
State of Florida Division of Workers Compensation. To apply for the exemption go to their website www.fldfs.com/wc.
3.
Surety Bond - A $2,000. Surety Bond.

RE-EXAM FEE-$50.00 (per exam) TO PALM BEACH COUNTY. APPLICANTS FOR ANY CATEGORY MAY TAKE A MAXIMUM
OF FOUR (4) EXAMS IN A TWELVE (12) MONTH PERIOD; MINIMUM BETWEEN TESTS IS 60 DAYS. YOU MUST REAPPLY AT
THE CONSTRUCTION INDUSTRY LICENSING BOARD OFFICE. AN ADDITIONAL RE-EXAM FEE WILL BE CHARGED BY
THE TESTING AGENCY
Applicants may request a 50% refund of application fees. The request must be in writing within 30 days of the initial submittal of the application and received prior to CILB review in order to receive a refund. If 30 days have passed and the application has not been reviewed for lack of completion, a refund will not be awarded or monies credited to a new application submittal. A staff error will result in a full refund
Page A
Rev. 7/14-I/E&R

Trade
PREREOTIISITE
S
(experience must be shown by documented proof)
Hands on Experience Required for Licensure
General Contractor
Buildins Contractor
Residential Contractor
Electrical Contractor
5 Years Supervisory Capacity
4 Years Supervisory Caoac ty
3 Years Supervisory Capac
7 Years Experience, 4 of which shall be as a Journeyman in a
Plumbing
HARV Contractor
Soecialtv
Contractor
Contractor
Snecialtv Trades that require licensure in Palm Beach Counfv
ACOUSTICAL/SUSPENDED CEILING
ALUMINUM SPECIALTIES
PAINTING
PAVER BRICK/PAVER SYSTEMS
CARPENTRY
CARPENTRY
CONCRETE
FINISH
FORMING
FABzuC AWNINGS
FENCE
& PLACING
CoTTNTERTOP (Eff.
1/15)
DECORATIVE METAL
DEMOLITION
DREDGING AND LAND FILLING
DRYWALL
Supervisorv Caoacitv.
7 Years Experience, 4 of which shall be as a Journeyman in a
Supervisory Capacity.
7 Years Supervisorv Caoacitv
3 Years Experience with 1-1/2 in a Supervisory Capacity
PAVING
PLASTERING
REINFORCING STEEL
RE-SCREENER/SCREEN REPAIR
ROOFING
SEAL COATING/STRIPING
SIGN CONTRACTOR/ELECTRICAL
SIGN CONTRACTORAION.ELECTRICAL
STRUCTURAL STEEL ERECTION
SWIMMING POOL CONSTRUCTION
SWIMMING POOL MAINTENANCE AND
REPAIR
GARAGE DOORS
GLASS AND GLAZING
GLINITE
HURRICANE SHUTTER/AWNING
INSULATION
IRzuGATION SPRINKLER
LIGHTNING PROTECTION SYSTEMS
LOW VOLTAGE (Eff. 6/14)
MARINE
MASONRY
TENNIS COURT
TILE, TERRAZZO AND STONE
LTNDERG ROUND/OVERT{EAD
TRANSMISSION LINES
UNDERGROUND UTILITIES
WINDOW AND DOOR
FLooRTNG (Eff. 6n4l
Credit Check, lnc.
Associated Credit
Lumbermen's
of
Asencies
is not all-inclusive. Please see disclaimer below'
1-877-616-5556
1-800-676-7640
L-954-77L-2LOO
West Palm Beach
Ft. Lauderdale
Ft. Lauderdale
We cannot recommend or endorse a particular Nationally Recognized Agency. The list provided above includes all the agencies in this area that we are aware of that currently meet the Board's reporting requirements. provided solely as a courtesy to assist you in locating resources.
is
Page B

Name: Date:
@lease make sure that all documentation has
be returned to vou
Check
been included
to turning in your application. An incomplete tr
$ Fee -(check) tr
tr tr
Paee
Photo
Clear and Legible Copy of Drivers License
Reciprocity Letter from Sponsoring County
applicable)
Signed and Dated Application tr tr tr tr
Pape2
Completed
If Yes to #6 - Copies of Current Licenses
Completed Corp/LLC Section
Notarized Section, completed
tr
Page 3
Completed
If Yes to any question
included a written explanation and documentation
Notarized Section, completed tr tr
D tr tr tr tr tr
tr tr tr tr
Pase 4 - Resume
Resume, Completed or Attached
Signed and Dated
Pase 5 - Verification of Experience
Completed Verification of Experience showing the years of experience
Copies of Contractors DL
License
Contracts
per month
applicable for experience)
Page 6 - Business Financial Statement
Copy of Current Company Bank Statement/Lefter.
Signed and Completed Form
Corporation Information
Copy of Company Page from Sunbiz.org
Copy of Annual Report from Sunbiz.org
Copy of Fictitious Name
applicable)
Pase 7- Qualifiers Resnonsibilitv
Notification - Filled out correctly
signed
Credit Reports
on Applicant
on Company being qualified
Company is less than six months old one
(l) in applicant and
(l) on each officer.
Page C

#
FOR
OF
OR
CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY
2300 N Jog Road, West Palm Beach, Fl 334 I l-27
Phone: (561) 233-5525
type
Received
Application fee must accompany the completed application. Application fee application has been entered on the record.
not returnable after
All checks must be made payable to BCC - Palm Beach Countv.
Applicant agrees to authorize the Construction Industry Licensing Board of Palm Beach County and its agents to obtaln such mtormatron concernlng appllcant's tlnanclal condrtlon ancl expenence as necessary from any source dealing with the applicant, even though said information might be deemed confidential.
Scotch Tape
Recent Photo Here
2"
Head
Shoulders
Passport Photo
NOTICE OF COLLECTION OF SOCIAL SECURITY NUMBERS FOR GOVERNMENT PI.JRPOSES: UNDER THE FEDERAL
PRTVACY ACT, DISCLOSURE OF SOCIAL SECURITY NUMBERS IS VOLUNTARY UNLESS SPECIFICALLY REQUIRED BY
FEDERAL STATUTE. IN THIS INSTANCE, SOCIAL SECI]RITY NUMBERS ARE MANDATORY PURSUANT TO TITLE
42
UNITED STATES CODE, SECTIONS 653 AND 654: AND SECTIONS 409.2677 AND 409.2598, FLORIDA STATUES, TO ALLOW
EFFICTENT SCREENING OF APPLICANTS AND LICENSES BY
TITLE ry-D CHILD SUPPORT AGENCY TO
ASSIJ.RE
COMPLIANCE WITH CHILD SUPPORT OBLIGATIONS. SOCIAL SECURITY NUMBERS MUST ALSO BE RECORDED ON
PROFESSIONAL AND OCCUPATIONAL LICENSE APPLICATIONS AND
ALL
WILL BE USED FOR LICENSEE IDENTIFICATION
PURSUANT TO THE PERSONAL RESPONSIBILITY AND WORK OPPORTUNITY RECONCILIATION ACT OF 1996 (WELFARE
REFOR]VI ACN.
Underthe provisions of Chapter 67-1876 Special Act, Laws of Florida, as amended, defining, regulating and governing contactors within the County of Palm Beach, Florida, I hereby apply for a certificate of competency to qualiff as a contractor in Palm Beach
County, Florida:
Applicant Sigrature Date
Check
by examination:
Uv reciprocity from Countv ctassifrcation/Trade cneek orcr
ERBSDBNTIAL
(Specifo which Trade)
U.S. Social Securi8 #: Drivers License #: Issuine State:
First Name: Middle: Last:
Home Address:
Business Address:
Home Phone:
State:
Cell Number:
Citizen of the United States?
tr
No
Place of
Date of
Alper the
CILB's Rule & Reeulstions # 26. the name of the business shall not be misleading as to the scooe of certification held
Company Full Leeal
INC/CORP/LLC (include d/b/a
applicable)
Bus. Phone:
Citv: State: Zioz Bus. Fax:
Email: Date Comoanv Est.
FEIN:
Page I
Rev. 07114 Exam/Recp.

Certificate to be issued:

Active

Inactive
I am qualifying for a : (check one)

Sole Proprietorship

Partnership

Corporation or LLC
1. Will you, as the Qualifying Agent, have any Ownership in this firm? (check one)

Yes

No
2. If No, give details: Percentage of Ownership
3. Will you be supervising employees of this company? (check one)
__________%

Yes

No
4. If No, give details:
5. If you are qualifying a 2nd Corporation, please furnish copies of stock certificate for each officer.
6. Do you hold any current licenses?

Yes (list and include copies)

No
List here:
Complete this section if you are a Corporation or an LLC:
Title Officer or Member Name Home Address, City State, Zip
STATEMENT OF QUALIFIERS RESPONSIBILITY
In making application to qualify a company, corporation, partnership, limited partnership, or any type of business entity, I understand that I, as qualifying agent, am completely responsible for the actions of said business entity as they relate to its construction business.
Further, I understand that the Construction Industry Licensing Board of Palm Beach County, by the authority granted to it, by the Special Act 67-
1876, as amended, holds the qualifying agent responsible for supervision of the sites as well as financial aspects of the entity's construction business, including, but not limited to, payment to subcontractors, suppliers, employees and Federal and State taxes.
Section 10 of the Special Act 67-1876 sets forth various prohibited activities and Section 11 identifies those acts for which disciplinary action may be warranted. I understand that the Construction Industry Licensing Board of Palm Beach County holds me, as qualifying agent, responsible for any violation of Sections 10 and 11 of the Special Act 67-1876, which may be committed by the business entity I qualify.
I further certify that I will immediately notify the Construction Industry Licensing Board of Palm Beach County, if I as qualifying agent shall sever connections with the firm, or I am no longer actively supervising the construction or installation work under contract.
Signature of (Applicant) Qualifier:
STATE OF } _______________________
COUNTY OF } _______________________
Subscribed and sworn to (or affirmed) before me on ____________________(date) by_________________________________(name of affiant, respondent or other signer). He/she is personally known to me or has presented________________________________ (type of identification) as identification.
_____________________________________
( NOTARY'S SIGNATURE AND SEAL)
Page 2
Rev. 07/14 Exam/Recp.

FOR
OF
OR
HAVE YOU OR ANY PERSON NAMED ON PAGE 2, THE ORGAI\IZATION BEING QUALIFIED, THE PRIOR FIRM,
OR ANY OTHER FIR]VIS YOU QUALIFY, OR HAVE QUALIFIED, EVER:
Filed bankruptcy, been a member of a
adjudicated as bankrupt, or in the
Drocess of bankruptcv proceedinqs?
Been a member of a
which failed to complete a contract, to pay all
contractors. material suppliers or employees on a contract?
Had any personal unpaid, past-due bills over 90 days, liens, judgments or lawsuits?
EYes
trNo trNo
EYes trNo
Had liens, suits or judgments of record or pending as a result of construction
5.
operations?
Been charged
acting as a contractor without a license, (issued NON, NOV
convicted of same, or
licensed as a contractor had any disciplinary action
(including probation, fine (s) (such as a
or reprimand) against such license by any State, County or municipality.
El
Yes tr No
Been found guilty of any crime other than a
violation?
your answer to #6 is yes, have your
rights been revoked?
your answer to #6 is yeso have you had your
rights restored?
EYes trNo
El
No
EYes trNo
answered yes to any ofthe above questions, please explain in detail on a separate attached sheet.
I certi$ that I will act for the partnership, firm or corporation for which I am qualifuing in all matters concerning the contracting business, and I will activelv supervise all construction work and be responsible for ascertaining that all such work is completed according to approved plans, applicable codes and good consffuction practice. I will immediately notiff the Consffuction Industry
Licensing Board of Palm Beach County if I sever connections with the partnership; firm or corporation concerned in this application, or I'm no longer actively supervising the construction work.
The undersigned hereby makes application for certification under the provisions of the Palm Beach County Certification Law,
Chapter 67-1876, Special Act, Laws of Florida, as amended, and vouches for the truth and accuracy of all statements and answers herein.
The undersigned hereby certifies that he/she will act only for himselflherself and that he/she is legally qualified to act on behalf of the business organization sought to be certified in all matters connected with its contracting business and that he/she has supervise construction undertaken by himself /herself or such business organization and that he/she full authority to will continue during this certification to be able to so bind said business organization. If at any time during this certification, he/she ceases to be able to so bind or act for the business organization, he/she will immediately notify the Construction Industry Licensing Board of Palm Beach
Counry in writing.
4. r.. tt. CILB', attachments, is grounds
or for disqualificati fahification
any information herein, including
information in this application is true
correct.
supplemental pages and
company's
legal name INC/CORPiLLC (include d/b/a
applicable)
Signature of (Applicant) Qualifier
Print Qualifying Agents Name
STATE
}
Subscribed by
on
(date)
(name of affiant, respondent or other
\ signer). He/she is personally known to me or has presented
(type of identification) as identification
Page 3
Rev.07/14 Exam/RecP.

FOR
OF
OR
Your Resume' is needed by the Construction Industry Licensing Board
Palm Beach County to properly assess the experience in the trade classification chosen.
Attach additional pages
needed.
past and present employers.
telephone numbers.
addresses. dates emploved.
description of
performed and supervised bv
Resume' must include vour experience to present date.
title and
For Example:
Construction
Kingston Street, Springdale, and
Employed
June 1984 to
December, 1988 single
54 Months Total, Foreman 24 Months, Supervised 4 To 8 Employees and Sub-Contractors on family residences (duties performed) Or, (attach your resume').
Certify the above information or attached Resume' is true and correct.
Date
Signature of Applicant
Page 4
Rev.07/14 Exam/RecP.

FOR
OF
OR
- AS
(To
Be Filted Out by the Contractor under whom exDerience was eained)
ALTERATIONS OF ANY KIND WILL VOID THIS VERIFICATION FORM
ATTENTION CONTRACTOR: COMPLETE THIS FORM. HAVE IT NOTARIZED AND RETURN
ADDRESS: CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY
2300 NORTH JOG ROAD, WEST PALM BEACH,
33411-2741
***CONTRACTORS MUST INCLUDE A
COPY OF THEIR DRIVERS LICENSE AI\D CONTRACTORS LICENSE***
Name of Applicant Is orlwas employed by (name of qualifier)
ComDany Name: Located At: (address)
Email:
From: Month/Year To: Month/Year
During the above dates, our records indicate the above named emolovee oerformed in the caoacitv of:
Job Duties performed while employed:
Total Time
Emnloved:
Years/Months Total Time in
Suoervisorv Capacitv:
Years/Months
I am the Qualifier for the above Construction Co. and hold or have held a Certificate/License #
ISSUED BY Asa Contractor.
(Print Qualifyinq
Asents Name )
Contact Phone (business) :
(Signature of Qualifying Agent)
Cell Phone:
STATE
)
Subscribed
on by
(date)
(name of af[ranl respondent or other signer). He/she is personally known to me or has presented
(type of identification) as identification.
SIGNATIIRE AND SEAL)
This form mav be duplicated.
Verification Forms must be furnished to substantiate the minimum experience required in the category for which application is made.
IF yOU
ARE OR WERE SELF-EMPLOYED - verification of required experience may be supplied from copies of past and current certificates competency or license, or original notarized letters from Building Officials or Licensing Agencies, plus signature and the customer's signature - one per month covering the reggelll1qC-EIlgll OR
@! A) copies of contracts with your of if possible, B) notarized letters from contractors you performed work for as a subcontractor (listing the time frame involved
Page 5
Rev. 07/14 Exam/Recp.

ffi.
FOR
OF
OR
Business
Statement
Be On This Form)
Company Name:
Company full legal name INC/CORP/LLC (include d/b/a if applicable)
Current Assets
Cash
Notes Receivable
Accounts Receivable
Stocks
Inventories
Other Current Assets
I
Current Assets
$
$ s
$
$
$
$
Fixed Assets
Current Liabilities
Notes Payable
year)
Accounts Payable
Accrued Taxes
Other Current Liabilities
Total Current liabilities
Notes Payable (due in more
year)
$
Mortsase Pavable
Other Liabilities
$
$
Total Lons Term Liabilities
$
Total Long term plus Current Liabilities $
$
$
$
$
$
Lons Term Liabilities
I certiff
the aboye
Statement is
and
Printed Name: Date Sipnature:
Page 6
Rev. 07114 Exam/Recp.

FOR
OF
OR
hereby certify
is the qualiSing agent
(Qualifiers Legal Name)
Company Full Legal Name INC/CORP/LLC (include d/b/a
applicable)
Located at
(Address)
State
and,
he
she have
act
firm
connected
business.
quali$ing
qualiff
will supervise the
the
of Competency issued.
further certiff
PaIm
Beach
if the above named
sever connections
the
is no
the
the applicant are the only oflicer, you sign here)
Witness: Printed Name:
Date:
Page 7
Rev. 07114 Exam/Recp.