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2. CONTRACTOR APPLICATION
4. PERMIT #
5. AMOUNT $
7. Applicant Information:
9. Contractor’s Name
10. Phone Number
12. Business Name
13. City
15. State
16. Zip Code
17. County
19. State License Information:
21. Type of State License or Registration (please check all that apply)

    1. Residential Home Builder
    2. Residential Specialty Contractor
    3. General Contractor

    1. Commercial Contractor
    2. Mechanical Contractor

    1. Plumbing Contractor
    2. Electrical Contractor
23. Mississippi and or Registration Number
24. Expiration Date
26. City of Moss Point License if General, Electricians, Plumbers or Mechanical License
28. Signature Authorization
30. The following individuals are hereby authorized to obtain permits or sign documents for the above named company. (When you decide to add another person’s name to the list at a later date, you must either send a written letter or sign the form yourself allowing that person to pull permits under the company’s name).
32. Contractor Signature
33. Date
35. Describe project:
37. Project Cost $
38. Homeowner name
40. Project Address
41. Flood Zone
42. Zone
44. Building Official Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field