This form is to be completed by each contractor who intends to bid for work that is assisted through the LIHP Housing Rehabilitation Program. Satisfactory completion of this form enables you as a contractor to be placed on the list of Available Contractors, that LIHP staff will distribute to eligible homeowners who are ready to invite bidders. Copies of current Nassau or Suffolk County Home Improvement Licenses and proof of insurance must be attached to this form. Please note that for the rehabilitation work in the towns of Southampton, East Hampton, Shelter Island and Mastic Beach Village a locally issued contractor's license is required.

I. General Information

Name of Firm:

Contractor License Number:

Firm Owner:

Contractor License Number:

Street Address of Firm:

Office Phone:

City:

State

Zip Code:

Firm Owner's Cell Phone:

Email:

Office Hours:

Year Firm Was Established:

Are you a General Contractor? (You handle all phases of work)

Yes

Are you a licensed lead contractor?

Yes

Are your workers trained on lead safe practices?

Yes

Do you have a RRP (Rennovation/Repair/Paint) certificate? (If so, please provide with uploaded documents below)

Yes

Are you a N.Y. State certified woman-owned business?

Yes

Are you a N.Y. State certified minority-owned business?

Yes

Contractors must attach evidence of licenses that are required by local governments. Our program also requires contractors to carry the following insurance coverage:
(NOTE: Attach proof of insurance and current license to this form using "Select File" upload button below.)

A. Comprehensive General Liability Insurance

a. Bodily injury $1,000,000 each occurrence

b. $2,000,000 general aggregate

c. $5,000,000 umbrella policy

B. Comprehensive Automobile Liability

a. $1,000,000 include coverage for hired and non-hired vehicles

C. Do you carry Worker's Compensation Insurance? (Attach certificate of Worker's Compensation Insurance to this form using "Select File" upload button below.)

Yes

Attach Proof of Insurance, Current License(s), Certificate of Worker's Compensation Insurance and RRP Certificate files here:
(Click Select File to Upload for each file to be uploaded)

Select File(s) to Upload:

II. Areas of Expertise

Please indicate the years of experience you have in any of the areas below:

Type of Work

General Carpentry	Roofing
Structural Support Repair	Window Replacement
Door Replacement	Siding
Concrete Repair	Plumbing
Floor Covering Replacement	Kitchen Cabinet Replacement
Foundation Wall Repair	Attic & Sidewall Insulation
Chimney Repair	Heating & Ventilation
Electrical	Lead Hazard Reduction
Other Type of Work: (Describe work & years experience)

List your three most recent jobs completed:

Name

Phone Number

Type of Work

Name

Phone Number

Type of Work

Name

Phone Number

Type of Work

DO YOU GUARANTEE YOUR WORK FOR ONE YEAR?

Yes

I authorize the LIHP program administrators to verify the above information and I certify that the above information is true and complete:

First Name

Last Name

Date:

Contractor Application Form