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2. CITY OF ELLISVILLE

   1 Weis Avenue

   Ellisville, Missouri 63011

   Phone: 636-227-9660   *   Fax: 636-227-9486

3. 

5. APPLICATION FOR PLUMBER / DRAIN LAYER LICENSE

7. (Must be renewed July 31 every year)

9. Date:*
   Date:
10. **New Ellisville License # (to be assigned by Ellisville Staff)
12. Plumbing Company Name:*
14. Plumber Name:*
16. Address:*
18. City:*
19. State:*
20. Zip:*
22. Office #: (Include Area Code):*
23. Fax #: (Include Area Code):
25. Cell Phone #:*
27. Email Address:

29. The following items MUST be included before your application will be processed:

    *Please ensure No Personal Information is included on any uploaded photos or documents... ie. SSN, DOB, Checking Account numbers, etc.

31. St. Louis County License #: ------  (Attach FRONT & BACK copy of license with Photo)

33. Upload License *

    Maximum upload size limit 20 MB

35. Upload Photo*

    Maximum upload size limit 20 MB

37. St. Louis County Bond Expiration Date:*
    St. Louis County Bond Expiration Date:
38. Upload Certificate of Liability Insurance showing City of Ellisville as the Certificate Holder:*

    Maximum upload size limit 20 MB

40. Once application is approved, a License Fee of $30 will be required at time of license pickup. Payable to the City of Ellisville either by check or credit card. After submittal of this form, you will be contacted at the phone number provided above and given payment options.
    

42. Plumber's Signature:*
43. Date:*
    Date:

47. ~ OFFICE USE ONLY ~

49. Approved by:
51. Date:
    Date:
53. St. Louis County Photo License:
55. Certificate of Liability Insurance, Exp. Date:

57. Please contact the City of Ellisville for payment arrangement:                                                           Cash, Check, and Credit Card options are available.
    

60. Version: 06/25/2018

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

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