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2. Company Name*
3. Phone Number*
5. Contact Name*
6. Secondary Phone Number
8. Company Address*
10. City*
11. State*
12. Zip Code*
14. Email
18. Type of Work*

    1. Bituminous Paver $100.00
    2. Electrician $100.00
    3. Excavator $100.00
    4. General Contractor $100.00
    5. HVAC $100.00
    6. Landscape/Paver $100.00
    7. Mason/Concrete $100.00
    8. Mechanical $100.00
    9. Plumber (055)
    10. Plumber (other) $100.00
    11. Roofer $100.00
    12. Sewer $100.00
    13. Waste Hauler $300
    14. Other
19. Plumbers
    Plumbers must submit a current State of Illinois Department of Public Health License (055 License).
21. For Other Please Specify Type
23. If you have a current State of Illinois license, please provide the type and license number
25. Surety Bond*
    Upload signed copy of $10,000 Surety Bond in the name of the Village of Riverside. A signed original will need to be sent to the Village Offices.
26. Certificate of Insurance*
    Upload a copy of your Certificate of Insurance with the Village of Riverside named as certificate holder. (Proof of worker's compensation should be indicated if required by the State.)
27. Worker's Compensation

    1. I certify that I am not required by the State of Illinois to carry worker's compensation insurance (sole proprietor, S corp, etc.)
28. State/Local License*
    Upload a copy of your state or local licenses (i.e. electric, 055 or roofing)
30. Payment
    The $100 licensing fee must be received by the Village Offices before the license can be issued. Please contact the office with any questions.
31. Payment Options*
    -- Select One --Mailing CheckPaying in Person(Plumber, no payment required)Request Invoice

    Please select a payment option. At this time, the Village cannot accept payment over the web or phone. Plumbers - there is no payment required.
32. Letter of Intent
    If you are a subcontractor for a larger project, please upload your signed letter of intent. This form is not intended for building permit applications.
34. Note
    There is a penalty for starting any work without a current contractor's license and/or building permit no less than double the cost of the permit.
36. Electronic Signature Agreement*

    I hereby agree to comply striclty with all applicable codes and ordinances of the Village of Riverside, during the course of work and have submitted a $10,000.00 Surety Bond naming the Village of Riverside and a Certificate of Insurance with the Village named as an additional certificate holder.
    
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
38. Electronic Signature*
39. Date*
    Date
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field