Free 48739.pdf - Indiana

APPLICATION FOR LEAD CONTRACTOR LICENSE
State Form 48739 (R5 / 2-08) Approved by State Board of Accounts, 2008

INDIANA STATE DEPARTMENT OF HEALTH
INSTRUCTIONS: 1.

Reset Form

INDIANA STATE DEPARTMENT OF HEALTH Lead and Healthy Homes Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250

This form must be used to apply for a lead contractor license pursuant to 326 IAC 23. If accessing this form on-line, you may print the blank form and fill it out by hand; or you may fill it in on-line, then save it to your computer and print a hard copy for submission with original signatures. Please type or print in ink. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207

http://www.in.gov/isdh/programs/lead/

2. 3.

APPLICATION TYPE

Type of application (check one): Initial license Renewal license

PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant name Last First Middle Initial

2. 3.

Company name: Company mailing address Street

Company telephone number:

( State

)

ZIP code

City

PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS

Pursuant to 326 IAC 23, the applicant shall provide the Department two (2) copies of a clear and recent one and one-half inch (1-1/2") by one and one-half inch (1-1/2") identifying color photograph to be attached to the license. Please enclose your photographs with this application.
LEAVE THESE SPACES BLANK FOR OFFICE USE ONLY

PART C: DESIGNATED REPRESENTATIVE PERSONAL AND TRAINING INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 4. Designated representative name Last First Middle Initial

5.

Birthdate
Day Year

6. /

Sex Male Female

7.

Height feet inches

8.

Weight pounds

9.

Eye Color

10. Hair Color

Month

11. Home telephone number ( ) -

/

NOTE: Pursuant to 326 IAC 23, any transfer of the designated representative status to another employee must be reported to the Department, in writing, within five (5) working days of the transfer.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 48739 (R5 / 2-08)

Application for Lead Contractor License 2/08

PART D: LICENSE RECIPROCITY

ARE YOU APPLYING FOR AN INDIANA CONTRACTOR LICENSE BASED ON LICENSE RECIPROCITY?: YES - follow instructions below NO - skip to Part E and complete the rest of the application Companies applying for an Indiana license to conduct lead-based paint activities as a contractor under license reciprocity (see 326 IAC 23-2-6.5) must do the following: Complete Parts A, B, C, D and H of this application and submit the following with the application. 1. A legible copy of all of the applicant's or designated representative's current lead-based paint program licenses. 2. Documentation that the applicant or designated representative meets experience and education requirements of 326 IAC 23-2-3. 3. Copies of applicant's or designated representative's approved Project Supervisor initial and refresher training certificates and proof that applicant or designated representative has passed an approved third-party exam for Project Supervisor. 4. An up-to-date copy of the contractor's written standard operating procedures that includes current compliance procedures. 5. The contractor's certificate of insurance from a company recognized or licensed by the Indiana department of insurance.
6. 7. Proof that the applicant or designated representative has attended an Indiana-approved lead-based paint two-hour Indiana Rules Awareness course. Payment of the $150 application fee (see Part G of this application).

PART E: CONTRACTOR MATERIALS TO BE SUBMITTED WITH APPLICATION

Any contractor seeking an Indiana Lead Contractor License or Re-approval must provide the following:
1. 2. A complete list of prior contracts for the previous thirty-six (36) months for lead projects, including names, addresses, and telephone numbers of persons for whom projects were performed. An up-to-date copy of the contractor's written standard operating procedures, which include current compliance procedures for the following regulatory programs: a)
b) c) d) e)

326 IAC 23-4-5 (Emission Standards for Sources of Lead),
326 IAC 23-4 and 5 (Lead Removal), 326 IAC 23-2-4 (Lead Management Personnel; Licensing), 329 IAC 10 (Solid Waste) 29 CFR 1926.62 (Occupational Safety and Health Standards, Subpart 1, Personal Protective Equipment).

3. 4. 5.

A description or any lead projects that the contractor conducted which were prematurely terminated or not completed, including the circumstances surrounding termination. A list of any contractual penalties related to lead-based paint activities that the contractor has paid for noncompliance with contract specifications. Copies of any and alI warning letters, Notice and Order of the Commissioner, Agreed Orders, citations, notices of violation, or findings of violation levied against the contractor by any federal, state, or local governmental agency for violations of regulations or other laws pertaining to lead activities, including names and locations of the projects, the dates, and a description of how the allegations were resolved. A description detailing all legal proceedings, lawsuits, warning letters to supervisors from ISDH or claims which have been filed or levied against the contractor or any of his past or present employees, while employed by said contractor, for lead-related activities.

6.

PART F: FINANCIAL RESPONSIBILITY

326 IAC 23-2-4(b)(12) requires that a contractor provide documentation of the contractor's financial responsibility with a current certificate of
insurance with at least five hundred thousand dollars ($500,000) of liability insurance. The company offering insurance coverage must be recognized or licensed by the Indiana Department of Insurance. The Indiana State Department of Health must be listed as a "certificate holder" on the insurance. Attach documentation of this financial responsibility. Any changes in the status of the contractor's financial responsibility must be reported, within five (5) working days, to the Indiana State Department of Health.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 48739 (R5 / 2-08)

Application for Lead Contractor License 2/08

PART G: CONTRACTOR LICENSE APPLICATION FEE Upon application for an initial or renewal lead contractor license, the applicant shall pay a fee in the amount of one hundred fifty dollars ($150). · · Make all checks and money orders payable to "ISDH Lead and Healthy Homes Program". Pursuant to 326 IAC 23-2-8(c), the nonrefundable application fee is not: Transferable from one (1) type of lead license to another, Transferable from one (1) person to another, Transferable to any other type of license issued by the department,

Unless requested by the applicant and approved by the department within three (3) days of submittal to the department or prior to application processing by the department, whichever is earlier. PART H: CERTIFICATION & SIGNATURE IMPORTANT · · Allow a minimum of six (6) weeks for processing a complete application package and receipt of your lead contractor license. Make sure you have completed all appropriate sections of this application and have included all required addenda. Sign and date the application and return it to the Cashier address shown on page one (1) of this application. Applications that are incomplete or contain errors in response to any questions on the form will result in a delay in processing and issuance of your lead contractor's license. All information requested on this application is MANDATORY for the administration and processing of your license application pursuant to 326 IAC 23. Except for scores on any examination, all other personal data received will be regarded as a public record subject to disclosure in accordance with IC 5-1 4-3 and 326 IAC 17-1-4. The person listed In Part C of this form (Designated Representative) must sign both of the signature cards below.

·

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I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application. I understand that should investigations disclose any falsifications of information submitted in this application, my lead contractor's license may be revoked. I have read Indiana's lead rule 326 IAC 23 and the U.S. Environmental Protection Agency's rule 40 CFR 745 "Lead: Requirements for Lead-Based Paint Activities in Target Housing and Child-Occupied Facilities; Final Rule" and I understand the requirements of those rules. I understand that failure to comply with requirements as outlined within federal, state, or local lead-related regulations may result in civil and/or criminal penalties.

SIGNATURE OF APPLICANT:________________________________________________ SIGNATURE OF DESIGNATED REPRESENTATIVE:____________________________________________ (Both signatures are required)

DATE SIGNED: DATE SIGNED:

/ /

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PART I: SIGNATURE CARDS (application will be denied if signature cards are not signed by designated representative)

THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEAD-BASED PAINT RELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 23. SIGNATURE OF DESIGNATED REPRESENTATIVE

THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING LEAD-BASED PAINT RELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 23. SIGNATURE OF DESIGNATED REPRESENTATIVE

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