Fillable Printable Form F500-104-000
Fillable Printable Form F500-104-000
Form F500-104-000
F500-104-000 Application for Pump Installer Combined General Contractor Registration 01-2017 Index: APP
Contractor Registration
PO Box 44450
Olympia WA 98504-4450
www.Lni.wa.gov
Application for Pump Installer
Combination General Contractor
Registration and Electrical Contractor
License
Submit all items as a completed package or we will be unable to process your application.
A complete application package includes:
This application signed and notarized.
Continuous Contractor’s Surety Bond form (F625-003-000)
Certificate of Insurance and/or Assignment form(s) for Insurance (original copies only)
Unified Business Identifier (UBI) and IRS Employer ID numbers and Corporation Number if applicable
Copy of the Secretary of State Application (required for corporations ― LLC or LLP)
Change Assignment of Administration/Master Certificate form (F503-009-000)
Application fee:
Contractor Registration Portion
2 Years
$113.40
Electrical Contractor License Portion
2 Years
$277.60
Administration/Master Assignment or Transfer
Assignment or Transfer
$41.60
Total Due
$432.60
Bond Requirements:
$12,000 General Contractor
You must submit an original continuous contractor’s surety bond (not performance, license, or permit bonds)
with an effective date and seal of the bonding company.
In lieu of a surety bond, you may submit an original Assignment of Account form which has been completed by
a bank. Washington State banks only.
Insurance Requirements:
Minimum Amount (Coverage must be for each occurance)
$50,000 Property Damage
$200,000 Public Liabilty
The original Certificate of Insurance or other insurance documents must include the following:
Policy Number
Effective Date
Signature of Agent
Expiration Date or Until Cancelled
Cancellation Clause
Amount of Each Occurrence Coverage
Important:
All documents (Certificate of Insurance, Bond/Assignment of Account, and the Application for Pump Installer
Combination General Contractor Registration and Electrical Contractor License (F500-104-000) must be
submitted with exactly the same business name on all documents. There can be no errors, corrections,
omissions, additions, alterations, or whiteouts on Bond or Insurance Documents.
Change Assignment of Administrator/Master Certificate (F503-009-000):
This combined Pump Installed General Contractor Registration/Electrical Contractor License application
requires that a certified (03) Pump and Irrigation specialty, (03A) Domestic Pump specialty, or (01) General
electrical administrator or master electrician be assigned to the business. Only one electrical
administrator/master electrician can be assigned to the business at a time. The administrator/master electrician
must either be an owner/principal or a supervisory employee who agrees to perform the duties of the
administrator/master as detailed in RCW 19.28.061. Form available online by clicking here
.
F500-104-000 Application for Pump Installer Combined General Contractor Registration 01-2017 Index: APP
Other Registration Numbers Required:
You may apply for a Washington State Business License (Unified Business Identifier (UBI) Master Business
License, at any local office of the Department of Labor and Industries, the Department of Revenue, the
Employment Security Department, or the Business License Service in Olympia.
You may apply online for your UBI at Master Business License Division
or contact DOR at 1-800-451-7985 or
online at www.dor.wa.gov.
Applicants having existing accounts number that are current the L&I’s Insurance Services, the Department of
Revenue, the Employment Security Department must use those number. IRS Employer Account Number
(federal EIN) must be provided. If you are a sole proprietorship and have no employees, you may use your
personal Social Security Number. You may also submit a copy of the completed IRS application.
Notice:
If any of the owners/officers have ever previously been registered in the State of Washington as a General or
Specialty Contractor or licensed/certified in the State of Washington as a General or Specialty Electrical
Contractor/Administrator/Electrician and have any unsatisfied final judgments that were files against the
previous registration/license/certification, this application will be denied. All previous
registrations/licenses/certifications, owners, and officers will be verified. Files may be in state archives which
may delay verification and registration.
If you have any questions, please contact the Tumwater office of Contractor Registration at 360-902-
5226 or the Electrical Licensing and Certification at 360-902-5269.
F500-104-000 Application for Pump Installer Combined General Contractor Registration 01-2017 Index: APP
Contractor Registration
PO Box 44450
Olympia WA 98504-4450
www.Lni.wa.gov
Application for Pump Installer
Combination General Contractor
Registration and Electrical Contractor
License
Contractor Registration
$113.40 (GL 3050)
Electrical Contractor License
$277.60 (GL 1450)
Administration/Master Assignment GL1555
$41.60 (GL 1555)
Maximum Total Due:
$432.60
Business Name (Limited to 30 characters)
Phone Number (include area code)
Parent Company Name
Business Mailing Address
City
County
State
Zip Code
Name of Designated Electrical Administrator/Master to be Assigned to This Business
Certificate Number
Indicate Your Business Structure (check one):
Individual Proprietorship
Limited Liability Corporation (LLC)
Partnership
Limited Liability Partnership (LLP)
Corporation
Check the type of pump installer contractor license/registration you are applying for (check one):
CC01/EC03
Pump and Irrigation Installer General Contractor/Electrical Contractor
CC01/EC03A
Domestic Pump Installer General Contractor /Electrical Contractor
The Designated Electrical Administrator must have the appropriate (01), (03), or (03A) certification for
the pump installer contractor license/registration check above.
Do you plan to hire or do you have employees?
Yes No
If yes, you must enter your Industrial Insurance Account Number here:
Have any of the principal owners/officers, under any other construction business name been
previously or are currently registered in Washington as a contractor?
Yes No
If yes, enter your previous registered business name?
Do you want your previous registration continued as a separate business?
Yes No
Do you want your previous registration listed as inactive?
Yes No
Are you currently licensed as an electrical contractor with this agency?
Yes No
If yes, enter your previous license number here:
Do you want your previous license placed out of business?
Yes No
Do you currently utilize electrical contractor deposit (CD) accounts?
Yes No
If yes, do you want to transfer any remaining funds in the account to the new license?
Yes No
Other Registration Numbers Required
Unified Business Identifier (UBI) Number
IRS Employer Identification Number
Industrial Insurance Account Number
Print Applicant’s Name
Applicant’s Signature
Applicant’s Fax Number (include area code)
Applicant’s Email Address
F500-104-000 Application for Pump Installer Combined General Contractor Registration 01-2017 Index: APP
UBI Number:
Officer/Member’s Addendum Instructions for Complete Legal Names and Addresses
The information on Lines 1 ― 6 is required for each owner, member, or corporate officer(s). Make additional
copies of this page if needed.
You must provide all required information on this application or it will not be processed.
1. Legal Name:
Your complete legal name, exactly as shown on your driver’s license or other
government-issued identification.
2. Social Security Number:
Federal law requires that you provide your Social Security Number
{(42 USC, Chapter 7, Subchapter IV, Part D, sec. 666(a)(13)}
3. Date of Birth:
Each individual named on the registration must provide a date of birth.
4. Driver’s License Number:
If you do not have a driver’s license, you may use the ID number on any
government-issued photo identification.
5. Residence Address:
This is the physical location of where you reside.
6. Title:
This is the position you hold the company. Each person listed as owner,
member, partner, or corporate officer must complete and have his or her
signature individually notarized. Note: if your business structure is a corporation
or LLC, you must provide a copy of your application or articles of amendment
from the Secretary of State.
*Out of state notary can use a separate sheet.
Agent Information:
• Must be listed at the Secretary of State’s Office.
• A person must furnish the information required (Social Security Number, driver’s license number, address,
birth date) and the notarized signature.
• A company of an attorney acting as an agent (such as CT Corp Systems) requires the UBI number and
address. The signature is not required nor does it require notarization.
If you have any questions, please contact the Tumwater office Contractor Registration at 360-902-5226
or Electrical Licensing and Certification at 360-902-5269.
This section is for departmental use only:
Contractor Code
Effective Date
Expiration Date
Registration/License Number Issued
Processor’s Initials
Month
Day
Year
Month
Day
Year
Cross Reference With
Cross Reference With
Date Processed
Electrical
Spec Code
Effective Date
Expiration Date
Registration/License Number Issued
Processor’s Initials
Month
Day
Year
Month
Day
Year
Administrator/Master Certificate Number
Cross Reference With
Date Processed
F500-104-000 Application for Pump Installer Combined General Contractor Registration 01-2017 Index: APP
UBI Number:
Contractor Registration Officers/Members Addendum
The following must be completed by all individuals associated with the registration.
1. Full Legal Name (First, Middle, Last) Exactly as shown on your driver’s license or other government-issued identification
2. Social Security Number
3. Date of Birth
4. Driver’s License Number
5. Residence Address (PO Box Addresses are not accepted)
City
State
Zip Code
6. Title
Owner
Partner
Spouse
Member
Officer
Agent:
NOTE: Corporation/LLCs are required to submit a copy of the Secretary of State’s Application or printout.
Signatures ― Must be signed in front of a notary.
I certify under penalty of perjury under the laws of the State of Washington that all statements, answers, and
representations made in this addendum are true and accurate.
Print Name
Signature
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
1. Full Legal Name (First, Middle, Last) Exactly as shown on your driver’s license or other government-issued identification
2. Social Security Number
3. Date of Birth
4. Driver’s License Number
5. Residence Address (PO Box Addresses are not accepted)
City
State
Zip Code
6. Title
Owner
Partner
Spouse
Member
Officer
Agent:
NOTE: Corporation/LLCs are required to submit a copy of the Secretary of State’s Application or printout.
Signatures ― Must be signed in front of a notary.
I certify under penalty of perjury under the laws of the State of Washington that all statements, answers, and
representations made in this addendum are true and accurate.
Print Name
Signature
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
RESET
F503-009-000 Change Assignment of Admin/Master Electrician Certificate 10-2016 GL Code 1555 Index: ASSN
Department of Labor and Industries
Electrical Licensing
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Change Assignment of
Administrator/Master
Electrician Certificate
Who is the designated Administrator of Master Electrician?
An administrator or master electrician is an individual who has passed either an administrator or master electrician
examination and holds an active administrator or master electrician certificate and who agrees to perform the duties
of the administrator/master as detailed in RCW 19.28.061
.
How do I become an Administrator or Master Electrician?
If you want to become an Administrator, contact the contracted testing agency, PSI, at 1-800-733-9267, to
schedule an exam. Upon passing, the passing reports and certification fee must be submitted.
If you want to become a Master Electrician, you must meet the qualifications outlined in RCW 19.28.191 and
submit an application to the department for pre-approval to test.
Instructions for Completing the Form:
1. Designated Administrator/Master Electrician Information:
Enter the name of the administrator or master electrician certificate holder who will be assigning or
unassigning to or from the Electrical/Telecommunications Contractor’s License.
A. Assigning/Unassigning Fee = $41.60
This form may be used to both assign and unassign a single administrator or master electrician to
and from an Electrical/Telecommunications Contractor at the same time with one fee (one person
per form).
B. If the administrator/master electrician who is assigning has not yet been issued a certificate number,
the certificate number section can be left blank.
2. Assigning ― Complete this portion when assigning from an Electrical/Telecommunications Contractor
Enter the name, license number, and address of the Electrical/Telecommunication Contractor the
administrator/master is to be assigned to. The assignment date is typically the date the assignment fee is
paid. The assignment date is typically the date the assignment fee is paid. The administrator/master must
sign the form in front of a Notary Public who must then sign and affix their notary seal.
A. If an administrator/master is assigning to a new Electrical/Telecommunication Contractor that has
not yet been issued a licensed number, the license number section can be left blank.
B. If assigning to an Electrical/Telecommunications Contractor, the Assignment Confirmation portion of
the form must also be signed. See number 5 below.
3. Unassigning ― Complete this portion when unassigning from an Electrical/Telecommunications Contractor
Enter the name, license number, and address of the Electrical/Telecommunications Contractor the
administrator/master is be unassigned from. The unassignment date is typically the date the unassignment
fee is paid. The administrator/master must sign the form in front of a Notary Public who must then sign and
affix their notary seal.
A. When unassigning, the Assignment Confirmation portion of the form does not need to be signed.
4. Notarization
The Notary Public must sign their name and affix their Notary Seal where indicated, and must fill in the other
portions of the notary section of the form.
5. Assignment Confirmation ― Required only when the Administrator/Master Electrician is assigning
An owner, partner, principal, or officer of the Electrical/Telecommunication Contractor, of file with the
department may sign as the Company Representative for the Electrical/Telecommunications Contractor.
The company representative must date the form and print and sign their name to confirm the assignment of
the Administrator/Master Electrician to the Electrical/Telecommunications Contractor’s license.
F503-009-000 Change Assignment of Admin/Master Electrician Certificate 10-2016 GL Code 1555 Index: ASSN
Department of Labor and Industries
Electrical Licensing
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Change Assignment of
Administrator/Master
Electrician Certificate
Section 1: Designator Administrator/Master Electrician Information
Administrator/Master Electrician’s Name (Last Name, First Name Middle Initial)
Date
Mailing Address
Administrator/Master Certificate Number
City
State
Zip Code
Phone Number (Include Area Code)
Join the Electrical listserv for email updates & notices by providing your email address here
Section 2: Assigned. Revise my status as shown below (Use Section 3 if necessary. Complete Section 5)
As of
I will be assigned to:
Month
Day
Year
Electrical/Telecommunications Contractor Name
Contractor License Number
City
State
Zip Code
I agree to perform the duties of the Administrator/Master Electrician as stated in Chapter 19.28 RCW and to
notify the department within 10 days of a change in my assignment as an Administrator/Master Electrician.
Date
Administrator/Master Electrician’s Signature ― Signature must be notarized
Section 3: Unassigned. Revise my status as shown below (Use 2 if necessary.)
As of
I will be unassigned from:
Month
Day
Year
Electrical/Telecommunications Contractor Name
Contractor License Number
City
State
Zip Code
I confirm that I am no longer performing the duties of the Administrator/Master Electrician as stated in Chapter
19.28 RCW and am notifying the department within 10 days of a change in my assignment as an
Administrator/Master Electrician.
Date
Administrator/Master Electrician’s Signature ― Signature must be notarized
Section 4: Notarization
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
Section 5: Assignment Confirmation (Confirmation required when Administrator/Master Electrical is assigning.)
I am the owner, partner, principal, or an officer in the contractor above. I confirm the above applicant is to be
assigned as the designated Administrator/Master Electrician for this contractor’s license to perform the
Administrator/Master Electrician’s duties per Chapter 19.28 RCW.
Date
Company Representative Printed Name
Signature
Department Use Only
Slip print here
Assignment
Separation
Reason Code
Separation Date
Initials
RESET
