Loading...
HomeMy WebLinkAboutNorthern Mechanical Contractors 26-02Nn CONTRACTOR LICENSE APPLICATION City of Oak Park Heights 14168 Oak Park Blvd. N. Oak Park Heights, MN 55082 TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439-4439 — FAX: (651) 439-0574 Email: jhultman@cityofoakparkheights,com Business Name: NORTHERN MECHANICAL CONTRACTORS Address: 1975 SENECA ROAD SUITE 100 EAGAN MN 55122 Telephone: ( 952 ) 923 6922 Fax: ( ) E-mail - RICHARDW(@NORTHERNMO.0 LICENSE REQUIREMENTS • Fee based on trade. State license is required for residential genera[ contracting, roofing, plumbing and fire protection. Mechanical Contractors require MN State Surety Bond. • Certificate of Insurance, minimum coverage, $100,000 per person, Public Liability; $250,000 per accident, Bodily Injury; and $100,000 Property Damage. CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy_ • Agreement to hold CITY OF OAK PARK HEIGHTS harmless for ALL claims of damage liability that may come against the license/permit holder. • Proof of WORKERS COMPENSATION INSURANCE if required, by law, to be carried. • State and Federal Tax Identification numbers pursuant to MN STATE STATUTE 270.72. • The CONTRACTOR further agrees to adhere to all OSHA STANDARDS, UNIFORM TRAFFIC CODES and any CITY CODES AND STANDARDS that may apply to this license. • Licenseperiod: January-1 to December-31 of each ear. Cancellation will occur upon failure to provided 'continued proof df insurance coverage__ PC - LICENSE CLASSIFICATIONS: Blacktopping - $50 Building Moving -$50 Concrete and Masonry - $50 Excavating/Grading - $50 Pool Installation - $50 Irrigation System Installation - $50 Commercial General Contractor - $50 Heating, Ventilation & A/C - $50 ** Attach copy of MN Mechanical Bond Outside Sewer & Water -$50 Siding - $50 Signs & Billboards - $50 COMPLETION OF THE WORKERS COMPENSATION INSURANCE ANDTAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. THESE FORMS ARE ATTACHED AND MADE PART OF THIS APPLICATION. Office Use Only: Liability Insurance Expiration: Worker's Comp. Insurance Expiration: Mechanical Surety Bond ID: Y�1 Mechanical Surety Bond Expiration: LEAD ID & Expiration: `~ � Date License Issued: I � 1 l ! - No. 1�0— 02— 0 LICENSE APPLICANT: Pursuant to Minnesota Statute 270.072 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required tc advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Service. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please provide the following information and return along with your application to the agency issuing the license. Do not return to the Department of Revenue. Licensing Authority: City of Oak Park Heights License Period: Annual: January 1 through December 31 Personal Information: (Complete only if applicable) Applicant's Name: Applicant's Address: City Social Security No. State Zip Code Business Information: (Complete only if applicable) Business Name: NORTHERN MECHANICAL CONTRACTORS Business Address: 197Fi-ENFGA ROAD....SUIIE 1 nn EAGAN ITN 55122 City State Zip Code Minnesota Tax Identification No.: 9219581 Federal Tax Identification No.: + _--. 2,42-boo`7 If a Minnesota Tax Identification number is not required, please explain: Date: 12/18/2025 Signature: Title: As-sis1a-nj&ro!ecMqnaad 44? PROOF OF WORKERS' COMPENSATION INSURANCE COVERAGE Minnesota Statue, Section 176.182, requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self -insure. This information will be collected by the licensinq agency and retained within their files. This information is required by law. Licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, failure to provide or falsely reporting this information may result in a $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Provide the information specified above, in the spaces provided, or certify the precise reason your business is excluded from compliance with the insurance coverage requirement for workers' compensation. Insurance Company (not the Insurance Agent): _Af3 t T,4 Policy Number _Zr_ 7-+ Dates of Coverage: I o P ;La, f 12l z0Z - OR - I am not required to have Workers' Compensation Insurance because: (check one) have no. employees covered by law; am self -insured (include permit to self -insure); or Other (specify) have read and understand my rights and obligations with regards to business licenses, "permits and Wotke'rs' Wrpensation coverage and hereby certify by my signature below that to the best_pj my knowledge, the information provided is true and correct. Date: !, Sign Printed Name of Signature f A7� t 015— Al j— Title/Position of Person Signing INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 Oak Park Boulevard, N. Oak Park Heights, MN 55082 NOTE:The following must be signed by an Officer of the,Corporation or by the Owner and notarized. In consideration for the granting of this license, the license applicant agrees to hold the City harmless from all damages and claims of damage which may arise by reason of any negligence on the part of the Contractor or the Contractor's agents or employees engaged in the performance of this Contract/Permit, and will indemnify the City for the amount of all claims, liens, expenses and claims for liens of work, tool, machinery, materials or insurance premiums and for the amount of all loss by reason of the failure of the Contractor to fully perform its obligation under this Contract/Permit, including but not limited to attorney fees and costs incurred relative to such claims and losses. / By: Date Cor e O r Individual Pro rietarship Owner Subscribed and sworn to before me this I94 day of(700 Notary Public. e. nne-a; County. My commission expires: _ `_3t, 2C. w., CYNTHIA DIANA WOLF Notary Public +_ Minnesota �+y My Commission Expires Jan 31, 2027 Updated: 01-01-2018 NORTENG-01 BHOFFM ACORO� CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DDIYYYY) `� 12118/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER Christensen Group, Inc. 9855 W 78th Street Suite 100 Eden Prairie, MN 55344-8004 Becka rnvne (A/c, No, Ext): (952) 653-1133 1 lac, No): INSURER A. Acuity, a Mutual Insurance Co 14184 INSURED Northern Engineered Systems Llc, Dba Northern Mechanical LNSURERB. Nautilus Insurance Co. 17370 Contractors INSURER C : 1975 Seneca Road INSURER D : Suite 100 INSURER E: Eagan, MN 55122 INSURER F : r1nV9QAa;FR t":FRTIFIC:OTEIllQMRirR- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUert POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH S 1,000,000 CLAIMS -MADE 17 OCCUR T7392 1/1/2025 1/1/2026 A �OCCURRENCE 92 ET�EQVaMapQW_ S 300,000 VIED EXP (Any oneperson) S 10,000 PERSONAL &ADVINJURY $ 1,000,000 OE"L AGGREP6TZLIMITAPPLIESPER: X POLICY i -- �a LOC GENERAL AGGREGATE 31000,000 PRODUCTS - COMPIOP AGG S 3,000,000 $ OTHER. A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per persanJ AUTO ZT7392 1/1/2025 1/1/2026 BODILY INJURY Per accident S OWNED SCHEDULED AUTOS ONLY AUUTTOSy�{�p PROPERTY acrid DAMAGE S J1ANY AUTOS ONLY Al}TO OMCY A X UMBRELLA LIAB OCCUR EACH OCCURRENCE S S,000,OOO AGGREGATE S 5,000,000 EXCESSLIAB [�X CLAIMS -MADE ZT7392 111/2025 1/1/2026 DED I X I RETENTION $ 0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE �YI VCEitlFA€MBER EXCLUDED) [ N i [Mrndrtory In NH) N /A 'i:T7392 111/2025 1/1/2026 X PER OTH- STATUTE ELEACHACCJDENT S 500,000 EL. DISEASE -EA EMPLOY SOO,000 $ E,L DLSEACF - POLICY LIMIT S 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below B Pollution Liability �C'PP2042231-11 111/2025 11112026 Aggregate 2,000,000 B Professional Liab CPP2042231-11 1/1/2025 1/1/2026 Aggregate 2,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Oak Park Heights is included as an Additional Insured on a the Commercial General Liability when required by written contract. TE CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 14168 Oak Park Blvd N Oak Park Heights, MN 55082 ACORD 25 (2016/03) ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD