Plumbing Contractors: Application for Registration

Plumbing Contractor

Application for Registration or Renewal

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Business Name ____________________________________________________________________________________

Address __________________________________________________________________________________________

City ________________________________ State ______ County ___________________ ZIP code + 4_____________

Telephone ______________________ Fax _______________________ FEIN OR SSN (#) _______________________

(Required)

Facility Mailing Address (if different from above)

Address __________________________________________________________________________________________

City ________________________________ State ______ ZIP code + 4 ______________

Confirmation of Employees (One selection must be marked)

❑ Yes ❑ No Do you have any employees (clerical, janitorial, plumbers, etc.) beside yourself? If yes, you are required

to have $500,000 Workers’ Compensation coverage on your Certificate of Insurance. If no, you must

complete the enclosed Affidavit of No Employees.

Type of Ownership

(One selection must be marked)

❑ Sole Proprietorship (Sole owner must be a licensed plumber.)

❑ Partnership (One of the partners must be a licensed plumber.)

List names, addresses and telephone numbers of each general partner.

❑ Corporation/Limited Liability Company (LLC)

List the exact full name of the corporation or limited liability company as on file with the Secretary of State.

List name, address and telephone number of the corporation or limited liability company’s registered agent.

Complete the following information for the Licensed Plumber of Record: (The Plumber of Record must be the sole

owner, if sole proprietor; a partner, if partnership; an officer, if a corporation; or a manager/member, if LLC.)

Name of Plumber _________________________________________ Telephone Number ________________________

Address __________________________________________________________________________________________

City ________________________________ State ______ County ___________________ ZIP code + 4 _____________

Plumbing License ID #________________________________ Plumbing License Expiration Date___________________

$150 annual registration fee (Registration fees are non-refundable.)

***__________________________________________________ _____________________

Original Signature of Plumber of Record Date

State of Illinois

Illinois Department of Public Health

Printed by Authority of the State of Illinois

IL 482-0679

IOCI 15-479

APPLICATION INSTRUCTIONS AND REQUIRED ATTACHMENTS LISTED ON REVERSE SIDE

FEES ARE NON-REFUNDABLE

Renewal Fee: $150

Reinstatement/Late Fee:$100

Returned Check Fee:$200

State of Illinois

Illinois Department of Public Health

Section 894.20 of the Plumbing Contractor Registration Code (77 Ill. Adm. Code 894) requires registration applicants

to attach the following information to this application:

❑ A legible copy of the valid plumbing license for the individual listed as Plumber of Record. This license must be valid

for at least 60 days after registration is issued. If the plumber’s license is issued by the city of Chicago, it is the respon-

sibility of the applicant to forward a copy of the plumber’s license to the Department, noting the name of the registered

contractor, within 15 days after the Chicago license is renewed.

❍ If this is a new corporation, also attach a copy of the Articles of Incorporation from the Illinois Secretary of State

and meeting minutes showing officers elected.

❍ If this is a new limited liability company, attach a copy of the Articles of Organization from the Illinois Secretary

of State and meeting minutes showing members/managers.

❍ If this is a partnership, and one of the partners is an apprentice plumber, attach a copy of the notarized

Partnership Agreement.

❍ If this is a foreign (out-of-state) corporation, submit a filed copy of the Authority to Transact Business in Illinois.

❑ Chicago licensed plumbers must provide proof of four hours in an approved continuing education course taken

AFTER October 1st of the renewal year.

❑ $150 annual registration fee (Registration fees are non-refundable.)

❑ Certificate of Insurance - Per occurrence: $100,000 general liability, $300,000 bodily injury, $50,000 property damage,

and $500,000 workers compensation. Plumbing contractors with no employees may elect to be exempt from workers

compensation (see the Affidavit of No Employees and Opt-Out form). The certificate must name the Illinois Department

of Public Health, Plumbing Program, 535 W. Jefferson St., Springfield, IL 62761, as certificate holder. The Department

will not accept binders or continuous certificates. Each applicant or registered plumbing contractor, or his or her desig-

nated insurance representative, shall provide the Department with the required Certificate of Insurance and notify the

Department in writing of any cancellations, material alterations or expiration at least 30 days prior to any such cancellation,

alteration or expiration. Certificate must be good for at least 60 days after registration is issued and must be in force at

all times for registration to remain valid. Failure to present a renewed certificate of insurance to the Department before the

expiration of the one on file will cause your registration to be suspended. Being suspended will cause your apprentice(s)

to lose time until the certificate is brought up to date. The name on the certificate must exactly match the name of the

business on the application.

❑ A surety/indemnification bond in the amount of $20,000 or a letter of credit in the same amount, for work performed in

accordance with this act naming the Department as beneficiary. Surety bond must be on the form provided by the

Department, must expire September 30, of the current year and cannot be a continuous bond. Front and back of form

must be completed. Signatures must be original. Name of principal must exactly match the name of the business on

the application. Cross-outs and white-outs are not accepted. Riders are not accepted.

❑ The Department WILL NOT allow a plumber to be the Plumber of Record for more than one company at one time.

The Department must be notified within 15 days of any changes in the business structure, name, or location; or of the addition

or deletion of the owner or officer who is the licensed plumber listed on this application. Failure to notify the Department of

this information is grounds for suspension or revocation of the plumbing contractor’s registration. This contractor registration

will expire on September 30, of the current year. Registrations are non-transferable for changes in ownership. The new

owner(s) must reapply.

RETURN APPLICATION WITH ALL ATTACHMENTS TO:

Illinois Department of Public Health

Plumbing Program

525 W. Jefferson St., 3rd Floor

Springfield, IL 62761

Telephone 217-524-0791 - Fax 217-524-5868

TTY (hearing impaired use only) 800-547-0466

Important Notice

This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Illinois Plumbing

License Law, 225 ILCS 320. Disclosure of this information is mandatory. Failure to provide any information could result in denial of the contractor license.

This form has been approved by the Forms Management Center.

Printed by Authority of the State of IllinoisIL 482-0679

IOCI 15-479