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1 APPLICATION FOR CHANGE OF STATUS CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY 2300 NORTH JOG ROAD, 2 nd Floor, Ste. 2W-61 WEST PALM BEACH, FL Website: pzbccert@pbcgov.org Phone: Fax #: INSTRUCTIONS FOR COMPLETING APPLICATION THIS COMPLETE, ORIGINAL APPLICATION, (NO FAXES), INCLUDING CREDIT REPORTS, BACKGROUND CHECK AND PAYMENT MUST BE IN OUR OFFICE BY THE 1 ST FRIDAY OF THE MONTH THAT YOU WANT THE BOARD TO CONSIDER YOUR APPLICATION. Application is complete if it includes the following: 1. APPLICABLE REVIEW FEE - Payable to the Board of County Commissions of Palm Beach County by check, money order or cash. ************* Please check off any item below that may apply to our application******************* Review Fee Balance Total Amount CHANGE OF COMPANY NAME $ $ $ NEW COMPANY $ $ $ ACTIVATE-AN INACTIVE CERTIFICATE $ $ $ REINSTATE-AN EXPIRED CERTIFICATE $ $ $ QUALIFY AN ADDITIONAL COMPANY $ $ $ PHOTO - 1 Recent Passport photo of applicant (MAXIMUM 2" x 2"). 3. A CLEAR COPY of a valid Driver's License, State ID, Resident Alien Card or Passport. If ID does not contain address a utility bill is required. 4. FINANCIAL STATEMENT - List the name of company, cash (ending balance from current bank statement) and whatever you are using for company (i.e. uck, equipment, etc.) Sole Proprietorship - if in applicant s name only (i.e. John Jones), fill in as a personal financial statement. Net Worth Requirements: 1. General, Building, & Residential $20, Carpeny, Demolition, Elecical, HARV, Plumbing, Roofing, Suctural Steel, Swimming Pool Consuction & Underground Utilities $10, Marine $5, All other Specialty Trades $2, Net Worth shall be defined as having a minimum of 50% in cash verified by a current company bank statement or bank letter (for newly established company only). 5. CREDIT REPORT to include a credit score. - Credit Reports (1) one for applicant and (1) one for company. If company is less than 6 months old (1) one for applicant and (1) one for each officer. In addition, a credit report for the company that you last qualified or owned, even if it was located in another state. Credit Reports must come from a nationally recognized credit agency and sent directly to our office. Credit Score requirement 660 or higher. Applicants with a credit score between 580 to 659 have two (2) options; (1) submit application once a credit score of 660 or above is obtained, or (2) pass a Florida CILB approved 14-hour financial responsibility course. Please use link to find a provider: 6. BACKGROUND CHECK- must be applied for and results submitted prior to handing in an application. Palm Beach County (ORI Number FL750157Z) Providers can be found at link below: ONCE APPLICATION HAS BEEN APPROVED BY THE BOARD, THE FOLLOWING INFORMATION IS REQUIRED TO OBTAIN AN ACTIVE CERTIFICATE OF COMPETENCY; ALL DOCUMENTS LISTED BELOW MUST 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 3. Surety Bond - A $2,000. Surety Bond. 4. Business Tax Receipt from the Tax Collector s Office. 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. 3/9/17-Change of Status Insuctions

2 Financial Responsibility & Stability Dear Applicant, as of 10/1/2015, the Consuction Indusy Licensing Board (CILB) has implemented a new ruling to obtain credit score criteria as part of the application process. You must submit a credit report (FICO derived) from a nationally recognized credit report agency, which includes a public records statement that records have been check at local, state and federal levels. You must meet a credit score of 660 or higher in order for your application to be considered. Applicants with a credit score between 580 to 659 have two (2) options; (1) submit application once a credit score of 660 is obtained, or (2) pass a Florida CILB approved 14-hour financial responsibility course. Should you choose option (2) you must contact an approved financial responsibility course entity by going to the web link listed below. Approved 14-hour Financial Responsibility Courses link: The approved Financial Responsibility Courses link is maintained by the Florida Department of Business and Professional Regulation (DBPR). Conactors Certification must receive the Certificate of Completion with your application for review. CILB Rule #6: Credit Reputation B. Credit Scores: Applicants with a credit score of 660 or higher meet the minimum credit reputation requirements for licensure. Applicants with a credit score between 580 to 659, must pass a Florida CILB approved 14-hour financial responsibility course and provide certification at time of application to meet credit reputation requirements for licensure; failure to do so will render the application incomplete. Applicants with a credit score below 580 or with no credit history do not meet the minimum credit reputation requirements for licensure and the application will be adminisatively denied by the Director. Unless otherwise prohibited by these Rules or the Special Act, the applicant may apply for licensure to the CILB again once the credit score is 580 or above. Form CC-027 Rev. 12/2/16 Informational Reference H

3 Partial List of Nationally Recognized Agencies (This list is not all-inclusive. Please see disclaimer below) Associated Credit Reporting Inc Sunrise Credit Check, Inc West Palm Beach Licenses Etc Naples Lumbermen s Ft. Lauderdale Disclaimer: 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. It is provided solely as a courtesy to assist you in locating resources. You must also order your credit reports as part of the application process; results must be sent directly to Conactors Certification from the Credit Reporting Agency prior to application submittal otherwise application will be deemed incomplete. (Intentional left blank) Page B

4 Conactors Certification Division Planning, Zoning & Building 2300 N. Jog Road, 2 nd Floor Suite 2W-61 West Palm Beach, FL Office (561) Fax (561) PZBCCERT@pbcgov.org Website: Background Fingerprint Service Providers Dear Applicant, as of 10/1/2015, the Consuction Indusy Licensing Board (CILB) has implemented a new ruling to perform livescan fingerprints. You must obtain fingerprints to comply with the application requiring a criminal background check on all applicants. Below is the Florida Department of Law Enforcement (FDLE) website which you may use to locate a livescan fingerprinting provider: Records/Documents/ApplicantLivescanService-ProvidersVendors.aspx The approved Livescan Providers link is maintained by the Florida Department of Business and Professional Regulation (DBPR). You may also check with your local law enforcement agencies, such as police departments and sheriff s offices to see if they provide livescan fingerprinting. The Palm Beach County Identifier (ORI Number) is FL750157Z. This number must be given to the fingerprinting provider in order for Conactors Certification to receive the results. Confirm with the Provider, prior to selection, that they can process your fingerprints using our ORI number. Conactors Certification must receive the fingerprint results prior to your application being reviewed. Please feel free to provide a copy of this document to the Fingerprint Provider. CILB Rule #7 (A): Criminal Background Checks: To demonsate that the applicant is of good moral character and is fit for licensure, the applicant must submit to a Level 2 criminal background check conducted by the Florida Department of Law Enforcement and the Federal Bureau of Investigation. The cost of the criminal background check is to be covered by the applicant. If the applicant is found to have a criminal background, the Board may deny issuance of a certificate of competency based upon: (1) the relationship of the crime to conacting; (2) the severity of the crime; or (3) the potential for public harm. However, the Board may consider as mitigating factors: (1) the length of time since the commission of the crime; and (2) evidence of rehabilitation of the applicant. The Board may not deny licensure to an applicant based solely upon a conviction or the applicant s failure to provide proof of restoration of civil rights. Form CC-026 Rev. 12/9/16

5 INSTRUCTIONS Name: Date: Check List (Please make sure that all documentation has been included prior to turning in your application. An incomplete will be returned to vou further E] $ Fee -(check) Paee 1 Photo Clear and Legible Copy of Drivers License Signed and Dated Application Paree2 Completed #1-6 If Yes to #5 - Qualifring a 2nd Company (need stock certificates for each officer) If Yes to #6 - Copies of Current Licenses Completed Corp/LLC Section Notarized Section, completed Page 3 Completed #1-8 If Yes to any question #1-8, included a written explanation and documentation Notarized Section, completed Pase 4 - Business Financial Statement Copy of Current Company Bank Statement/Letter. Signed and Completed Form Cornoration Information Copy of Company Page from Sunbiz.org Copy of Annual Report from Sunbiz.org Copy of Fictitious Name (if applicable) Pase $ Oualiliers Resoonsibilitv Allidavit Notification - Filled out correctly & signed Credit Reports One (1) on Applicant One (l) on Company being qualified One (1) on previously owned or qualified company If Company is less than six months old one (1) on applicant and one (l) on each officer. Page C

6 APPLICATION FOR CERTIFICATE OF COMPETENCY CHANGE OF STATUS CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY 2300 N Jog Road, West Palm Beach, Fl Phone: (561) Please type or CLEARLY print all information Received Application fee must accompany the completed application. Application fee is not returnable after application has been entered on the record. All checks must be made payable to BCC - Palm Beach County. Applicant agrees to authorize the Consuction Indusy Licensing Board of Palm Beach County and its agents to obtain such additional information concerning applicant's financial condition and experience as necessary from any source dealing with the applicant, even though said information might be deemed confidential. Scotch Tape Recent Photo Here 2" x 2" Head & Shoulders Passport Photo NOTICE OF COLLECTION OF SOCIAL SECURITY NUMBERS FOR GOVERNMENT PURPOSES: UNDER THE FEDERAL PRIVACY ACT, DISCLOSURE OF SOCIAL SECURITY NUMBERS IS VOLUNTARY UNLESS SPECIFICALLY REQUIRED BY FEDERAL STATUTE. IN THIS INSTANCE, SOCIAL SECURITY NUMBERS ARE MANDATORY PURSUANT TO TITLE 42 UNITED STATES CODE, SECTIONS 653 AND 654: AND SECTIONS AND , FLORIDA STATUES, TO ALLOW EFFICIENT SCREENING OF APPLICANTS AND LICENSES BY A TITLE IV-D CHILD SUPPORT AGENCY TO ASSURE COMPLIANCE WITH CHILD SUPPORT OBLIGATIONS. SOCIAL SECURITY NUMBERS MUST ALSO BE RECORDED ON ALL PROFESSIONAL AND OCCUPATIONAL LICENSE APPLICATIONS AND WILL BE USED FOR LICENSEE IDENTIFICATION PURSUANT TO THE PERSONAL RESPONSIBILITY AND WORK OPPORTUNITY RECONCILIATION ACT OF 1996 (WELFARE REFORM ACT). Under the provisions of Chapter Special Act, Laws of Florida, as amended, defining, regulating and governing conactors within the County of Palm Beach, Florida, I hereby apply for a certificate of competency to qualify as a conactor in Palm Beach County, Florida: Applicant Signature Date Current Certificate of Competency : U- Classification/Trade Check One: GENERAL BUILDING RESIDENTIAL ELECTRICAL PLUMBING HARV SPECIALTY (Specify which Trade) U.S. Social Security #: Drivers License #: Issuing State: Applicant's Legal First Name: Middle: Last: Home Address: Home Phone: City: State: Zip: Cell Number: Citizen of the United States? Place of Birth: Date of Birth: Yes No As per the CILB's Rule & Regulations #8A, the name of the business shall not be misleading as to the scope of certification held Company Full Legal Name: INC/CORP/LLC (include d/b/a if applicable) Business Address: Bus. Phone: City: State: Zip: Bus. Fax: Date Company Est. FEIN: Page 1 Rev. 07/14 - Chg Stat.

7 APPLICATION FOR CERTIFICATE OF COMPETENCY CHANGE OF STATUS 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) 4. If No, give details: % Yes No 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 consuction business. Further, I understand that the Consuction Indusy Licensing Board of Palm Beach County, by the authority granted to it, by the Special Act , as amended, holds the qualifying agent responsible for supervision of the sites as well as financial aspects of the entity's consuction business, including, but not limited to, payment to subconactors, suppliers, employees and Federal and State taxes. Section 10 of the Special Act sets forth various prohibited activities and Section 11 identifies those acts for which disciplinary action may be warranted. I understand that the Consuction Indusy Licensing Board of Palm Beach County holds me, as qualifying agent, responsible for any violation of Sections 10 and 11 of the Special Act , which may be committed by the business entity I qualify. I further certify that I will immediately notify the Consuction Indusy 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 consuction or installation work under conact. 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 - Chg Stat.

8 APPLICATION FOR CERTIFICATE OF COMPETENCY CHANGE OF STATUS HAVE YOU OR ANY PERSON NAMED ON PAGE 2, THE ORGANIZATION BEING QUALIFIED, THE PRIOR FIRM, OR ANY OTHER FIRMS YOU QUALIFY, OR HAVE QUALIFIED, EVER: 1. Filed bankruptcy, been a member of a firm adjudicated as bankrupt, or in the Yes No process of bankruptcy proceedings? 2. Been a member of a firm which failed to complete a conact, to pay all subconactors, Yes No material suppliers or employees on a conact? 3. Had any personal unpaid, past-due bills over 90 days, liens, judgments or lawsuits? Yes No 4. Had liens, suits or judgments of record or pending as a result of consuction operations? 5. Been charged with acting as a conactor without a license, (issued NON, NOV or CITA), convicted of same, or if licensed as a conactor had any disciplinary action (including probation, fine (s) (such as a CITA or reprimand) against such license by any State, County or municipality. Yes Yes No No 6. Been found guilty of any crime other than a affic violation? Yes No 7. If your answer to #6 is yes, have your civil rights been revoked? Yes No 8. If your answer to #6 is yes, have you had your civil rights restored? Yes No If you answered yes to any of the above questions, please explain in detail on a separate attached sheet. I certify that I will act for the partnership, firm or corporation for which I am qualifying in all matters concerning the conacting business, and I will actively supervise all consuction work and be responsible for ascertaining that all such work is completed according to approved plans, applicable codes and good consuction practice. I will immediately notify the Consuction Indusy 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 consuction work. The undersigned hereby makes application for certification under the provisions of the Palm Beach County Certification Law, Chapter , Special Act, Laws of Florida, as amended, and vouches for the uth and accuracy of all statements and answers herein. The undersigned hereby certifies that he/she will act only for himself/herself 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 conacting business and that he/she has full authority to supervise consuction undertaken by himself /herself or such business organization and that he/she 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 Consuction Indusy Licensing Board of Palm Beach County in writing. As per the CILB's Rule & Regulations #1C, falsification of any information herein, including all supplemental pages and attachments, is grounds for disqualification. I hereby swear or affirm the information in this application is ue & correct. Print company's full legal name INC/CORP/LLC (include d/b/a if applicable) Print Qualifying Agents Name 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 3 Rev. 07/14 - Chg Stat.

9 APPLICATION FOR CERTIFICATE OF' COMPETENCY CHANGE OF STATUS Company Name: Business Financial Statement (Must Be On This Form) Company full legal name INC/CORPiLLC (include d/b/a if applicable) Current Assets Cash $ Notes Receivable $ Accounts Receivable $ Stocks $ Inventories $ Other Current Assets $ I Total Current Assets $ Fixed Assets Office Equipment $ Car. Trucks. & Eouioment $ Real Estate $ Other Fixed Assets s Total Fixed Assets $ Total Fixed Assets, plus Current Assets $ Notes Pavable (within 1 Year) Accounts Payable $ Accrued Taxes $ Other Current Liabilities $ Total Current liabilities $ Notes Payable (due in more within I year) $ Mortgage Payable $ Other Liabilities $ Total Lone Term Liabilities $ Total Lone term plus Current Liabilities s s Current Liabilities Lons Term Liabilities -) Total Liabilities I certify that the above Financial Statement is ue and correct. Printed Name: Date Sisnature: Page 4 Rev. 07/14 - Chg Stat.

10 ffi APPLICATION FOR CERTIFICATE OF COMPETENCY CHANGE OF STATUS ALIFIERS RESPONSIBILITY AFFIDA I hereby certis that (Qualifiers Legal Name) is the quali$ing agent for Company Full Legal Name INC/CORP/LLC (include d/b/a if applicable) Located at (Address) City and, that he / she have the authority to act for the lirm or corporation in all matters connected with our conacting business. To take the quali$ing examination to qualiff the company and will supervise the consuction or installation conacted for, under the Certificate of Competency issued. I further certi$ that we will immediatelv noti& The Consuction Indus"y Licensins Board of Palm Beach Countv. if the above named Qualifying Agent shall sever connections with the firm, or is no longer actively supervising the consuction or installation work under conact. Signature of Corporate Officer: (other than applicant qualiffing corp.) (If you the applicant are the only oflicer, you sign here) Witness: Printed Name: Date: Page 5 Rev. 07/14 - Chg Stat.