2. CONCRETE FLATWORK LICENSE APPLICATION

4. The time period for this license is January 1 through December 31 of the year it is submitted.  Licenses must be renewed each year.

6. Business Name*
8. Mailing Address*
10. City*
11. State*
12. Zip Code*
14. Business Phone*
15. Cell Phone
17. Email Address*
19. Type of Ownership*

    1. Sole Proprietor
    2. Corporation
    3. Partnership
21. Owner (Office of Corporation)*
23. Address*
25. City*
26. State*
27. Zip Code*
29. Name of the Person Authorized to Apply for Permits on Behalf of the Business*
31. Name of Person Authorized to Apply for Permits on Behalf of the Business

    List Additional Name if Needed

33. Name of Person Authorized to Apply for Permits on Behalf of the Business

    List Additional Name if Needed

35. City of Rock Island Construction Standards
    City of Rock Island Construction Standards
37. I have read and will follow the City of Rock Island's Construction Standards.*

    1. Yes
    2. No

39. A license fee of seventy-five ($75) is due payable to the City of Rock Island at the time this license application is submitted.  

    Permits will not be issued until the license fee is paid and a current concrete flatwork bond is on file.

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