APPLICATION REQUIREMENTS Failure to include the following may delay the processing of your application.

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1 BUILDING DEPAMEN (440) FAX (440) : All ontractors/ubcontractors FOM: ity of Avon Building Department JE: ontractor egistration and egistration equirements EGIAI I EQUIED OF ALL A AND A PEFOMING WOK, O POVIDING EVIE OVEED BY HE BUILDING ODE, PIO HE IUANE OF A PEMI (hapter 1444 of the ity of Avon odified Ordinances). ontractors who begin work in the city without first registering may be subject to a stop work order and court citation. he fine for this offense is set forth in ection of the odified Ordinances of the ity of Avon. APPLIAI EQUIEMEN Failure to include the following may delay the processing of your application. 1. EGIAI FEE $75.00 heck payable to the ity of Avon. a. Additional $75.00 is required if work started prior to registration. 2. OMPLEED APPLIAI a. equired: Pages 1-4 b. Including notarized page 4 3. $10,000 LIENE PEFOMANE BD (Pages 5 & 6) a. Only original bonds will be accepted. b. Bond is to expire December 31 st of the current year. If registering after December 1 st the bond may be written so that it will expire on December 31 st of the following year. c. he ity of Avon does provide a bond form. 4. IA egional Income ax Agency (Pages 7 & 8) 5. LIABILIY INUANE a. Name the ity of Avon as ertificate Holder. (ity of Avon does not need to be listed as Additional Insured) b. Bodily Injury in the amount of $100,000/$300,000 (per person) for accidental injury. c. Property Damage in the amount of at least $50, AE EIFIAI Attach a copy of the state license for Electrical, HVA, Plumbing, Automatic prinklers and Fire Protection, and Alarm ystems 7. OHIO BUEAU OF WOKE' OMPENAI EIFIAE Full completion of the form serves as registration with the ity of Avon Income ax Department as required by hapter 880 of the axation ode of the ity.

2 ANNUAL A AND A BUINE EGIAI FOM ANNUAL A AND A BUINE EGIAI FOM Name of ompany (DBA): PIN Name of ontact Person: Phone: Fax: ell: FED ID: Address of Office/Home: ity: tate: Zip ode: Nature of Business: (For Example: General, oncrete, Electrical, oofing, Plumbing, etc.) tate License No.: Worker s omp. No.: NOE: ALL LIENE/A EGIAI I LIMIED HE ALENDA YEA OF IUANE. ontractor egistration Fee: $75.00 per calendar year & an additional $75.00 will be charged if work is started prior to registration. EGIAI I EQUIED OF ALL A AND A PEFOMING WOK, O POVIDING EVIE OVEED BY HE BUILDING ODE, PIO HE IUANE OF A PEMI (hapter 1444 of the ity of Avon odified Ordinances). ontractors who begin work in the city without first registering may be subject to a stop work order and court citation. he fine for this offense is set forth in ection of the odified Ordinances of the ity of Avon. *OLE POPIE, PANEHIP AND UN-INOPOAED BUINEE: Provide names, addresses, and social security numbers of all owners on the back of this form. Will you have employees working in the ity of Avon? If so, how many? Applicant s ignature: Date: BE OMPLEED BY HE IY OF AV BUILDING DEPAMEN Fee Amount Paid: eceipt No.: Date: License No.: Page 1 of 8 Job ite/project: Approved By: Date:

3 ANNUAL A AND A BUINE EGIAI FOM 1. Does your business utilize subcontractors? 2. If your answer to Question 1 is 'Yes," have you listed all subcontractors in Block No. 17 of this application? 3. If your answer to Question 1 is "Yes," do you certify that all subcontractors utilized will obtain a ertificate of egistration from the ity prior to being utilized in any project in the ity? 4. Do you certify that all individuals being issued an I Form 1099 will be considered independent contractors and will obtain a ertificate of egistration from the ity prior to being utilized in any project in the ity? 5. Is evidence attached from a proper licensing authority, if applicable, that the applicant has received all necessary licenses? If "Yes," please list license registration type: License ype: License #: tate: _ YE NO License ype: License #: tate: 6. Do you certify that your business has not had a license revoked in any state or municipality? 7. Do you certify that your business has not been penalized or debarred from any public contract in the previous five (5) years for providing falsified certified payroll records or other violation of the Fair Labor tandards Act? _ 8. Do you certify that your business maintains a substance abuse policy for its personnel per Ohio Governor's Executive Order No ? 9. Does your business have current Ohio Workers' ompensation overage and is a copy attached? 10. If your answer to Question 9 is "Yes," do you certify that your business does not have a Bureau of Workers' ompensation Experience Modification ating greater than 2.0? If no, please explain: 11. Do you certify that your business has not had any "serious," "intentional," or "willful" violations of any Occupational afety and Health Administration regulations in the previous two (2) years? 12. Do you certify that your business has not had any convictions for violations of the Avon Building or Zoning odes within the previous five (5) years? If no, please explain: 13. Have you obtained, and attached, the original $10,000 license performance bond required by ity of Avon odified Ordinance ection ? 14. Do you certify that your business has not had any performance or license performance bonds exercised on any projects within the previous ten (10) years? If no, please explain: 15. Does your business have a ertificate of Liability Insurance Policy with a policy limit of at least $100,000 each occurrence? If "No" what are your limits? 16. Have you attached a copy of the ertificate of $ Liability Insurance Policy? Each Occurrence Page 2 of 8

4 ANNUAL A AND A BUINE EGIAI FOM 17. (equired) FOLLOWING I A LI FO A HA WILL BE UED: INLUDE ADDEE AND A INFOMAI. HI LI MU EAMAIN UEN AND HOULD BE UPDAED IN WIING WIH HE IY A NEEAY. Name of ubcontractor: Address and/or ontact Info: rade: Page 3 of 8

5 ANNUAL A AND A BUINE EGIAI FOM All contractors (whether engaged as a prime or subcontractor) must fully comply with all applicable city, state and federal codes including, but not limited to: worker's compensation laws, unemployment compensation laws (whether state and/or federal), all applicable withholding taxes for employees, and applicable permit fees. Failure to comply may result in a fine and/or imprisonment as otherwise provided by law as well as revocation of registration. I,, BEING DULY AUHOIZED BY HE A O A EPD HE ABOVE QUEI, DO HEEBY EIFY AND DELAE UNDE PENALY OF PEJUY, HA I HAVE EAD ALL OF HE FOEGOING ANWE, AND HA HOE ANWE AE UE HE BE OF MY AUAL KNOWLEDGE, AND BELIEF, AND HAVE HAD HE OPPOUNIY EVIEW HAPE 1444 OF HE AV ODIFIED. ODINANE AND WILL ADHEE AND OMPLY WIH ALL EQUIEMEN OF HAPE igned: Date: Print Name and itle: AE OF OHIO ) ) ss OUNY OF ) Before me, a Notary Public in and for said ounty and tate, personally appeared the above-named, who acknowledged before me that did sign the foregoing instrument and that the same is free act and deed. IN WINE WHEEOF, I have hereunto affixed my name and official seal at, Ohio, this da y o f, 2 0. (EAL) Notary Public My ommission Expires: Page 4 of 8

6 ity of Avon-Building Department hester oad Avon, OH (440) LIENE PEFOMANE BD Know all men by these presents, that as principal and as urety are held firmly bound unto the ity of Avon, or to any of its officers, for the use of any person, persons, firm or corporation with whom such Principal shall contract to construct, alter, repair, add to, subtract from, reconstruct or remodel any building structure or appurtenance thereto or any part thereof, in accordance with the provisions and the requirements of the Building ode of the ity of Avon, in the penal sum of en housand Dollars ($10,000.00) lawful money of the United tates, for the payment of which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. he conditions of the above obligation are such, that whereas the above Principal has made application to the Building Inspector for a license as a contractor to engage in the business to construct, alter, repair, add to, subtract from, reconstruct, or remodel any building, structure or appurtenance thereto or any part thereof as required by the Building ode of Avon during the year beginning and ending December 31,. Now, therefore the said agrees that it shall well and truly indemnify, keep and save harmless the ity of Avon, or any Page 5 of 8

7 of it s agents or officials for the use of any person, persons, firm or corporation with whom such contractor shall contract to do the work, and shall indemnify and pay any such person, firm or corporation for damage sustained on account of the failure of such contractor to perform the work so contracted for in accordance with the provisions of the Building ode of Avon, and any and all lawful rules and regulations promulgated under the authority thereof, and from or by reason or on account of anything done under and by virtue of any permits issued under such license for the doing of any work, required to be done in the construction, alteration, repair, addition to, subtraction from, reconstruction or remodeling of any building, structure or appurtenance thereto or any Part thereof. he said further agrees to pay all damages for loss that may occur from any act, neglect or carelessness of the principal, its agents or employees or any other under his or its supervision or direction or any subcontractor from such work pertaining to said business or occupation or from poor or defective work material. his License/Performance Bond is to remain in full force and effect throughout the calendar year PINIPAL ignature Date Address EAL UEY: ignature Date Address: 11/4/15 Page 6 of 8

8 BUINE EGIAI FOM 48 MUNIIPALIY FEDEAL IDENIFIAI NUMBE OIAL EUIY NUMBE (OMPLEE LY IF A OLE POPIE) FILING AU: OPOAI EAE/U LL N-POFI PANEHIP -OP. OLE POPIE IA LOAI NAME AND ADDE A UED FO BUINE PUPOE BUINE NAME: PHE: ( ) ADDE: IY: AE: ZIP: BUINE NAME: IF OPOAE IDIAY, GIVE NAME AND ADDE OF PAEN OMPANY MAIN OFFIE ADDE: IY: AE: ZIP: IF OLE POPIEHIP, GIVE OWNE NAME AND HOME ADDE NAME: PHE: ( ) ADDE: IY: AE: ZIP: WHA DAE DID YOU BEGIN OPEAI IN A IA MUNIIPALIY? PLEAE LI HE OMPANY NAI ODE O HEK HE BOX HA BE DEIBE HE OMPANY BUINE YPE NAI ANPOAI N MANUFAUING MANUFAUING WHOLEALE EAIL FINANE EVIE PLI ADMINIAI N LAIFIAI EMPLOYEE INFOMAI DO YOU HAVE ANY EMPLOYEE? (HEK LY E) YE NO AE A UILIZED? (HEK LY E) *IF YE OMPLEE EVEE IDE. YE* NO IF YOU HAVE EMPLOYEE POEED WIH EMPLOYEE INFOMAI. IF YOU DO NO HAVE EMPLOYEE POEED HE POFI/LO EI. NUMBE OF EMPLOYEE A IA LOAI: MHLY GO PAYOLL A IA LOAI: WILL YOU BE WIHHOLDING EIDENE AX LY? YE NO END WIHHOLDING AX FOM BUINE NAME: PHE: ( ) AE OF: ADDE: IY: AE: ZIP: IF YOU AE A N- POFI OGANIZAI P HEE AND IGN A BOM POFI/LO INFOMAI ENDING DAY OF FIAL YEA IF OHE HAN ALENDA YEA / MH DAY / YEA END NE POFI AX EUN BUINE NAME: PHE: ( ) AE OF: ADDE: IY: AE: ZIP: HE INFOMAI HEEBY MIED I UE AND OE. IGNAUE: DAE: PIN NAME: ILE: PHE: EGIAL INOME AX AGENY AN: BUINE EGIAI P.O. BOX BOADVIEW HEIGH, OH LEVELAND LL FEE: (800) 860-IA (7482) OLUMBU LL FEE: (866) 721-IA (7482) DD: (440) YOUNGWN LL FEE: (866) 750-IA (7482) FAX: (440)

9 A INFOMAI MUNIIPALIY: ADDE OF UI IE: BUILDING PEMI #: AL A AMOUN: $ As the contractor, will your company be withholding local income tax from all employees on the job? YE NO OMPANY/ADDE - IY, AE AND ZIP OFFIE/OWNE NAME PHE NUMBE OIAL EUIY O FEDEAL I.D. NUMBE EIMAED A DAE NUMBE OF EMPLOYEE EIMAED WAGE PE MH ADE G EN A A A A A A A If necessary attach a separate sheet he information requested on this form is essential to the establishment of your account and will be held in strict confidence. Please complete and sign this egistration Form and return within 15 days. Prompt completion of this form now can save you the expenditure of additional time and effort in the future. If you have any questions please contact the Business egistration Department at one of the numbers below. hank you for your cooperation. END EPE : EGIAL INOME AX AGENY AN: BUINE EGIAI P.O. BOX BOADVIEW HEIGH, OH LEVELAND LL FEE: (800) 860-IA (7482) DD: (440) OLUMBU LL FEE: (866) 721-IA (7482) FAX: (440) YOUNGWN LL FEE: (866) 750-IA (7482)