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HomeMy WebLinkAboutMidwest Electric and Generator 26-03CONTRACTOR 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 Telephone: (( I } 1 S Fax: E-mail �P.r'm i 5 1►n i _ aPS+G��,��, rt�r5 .. �D w LICENSE REQUIREMENTS • Fee based on trade. State license is required for residential general 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. • License period: January 1 to December 31 of each year. Cancellation will occur upon failure to provided continued proof of insurance coverage. LICENSE CLASSIFICATIONS: Commercial General Contractor - $50 Blacktopping - $50 Heating, Ventilation & A/C - $50 Building Moving -$50 ** Attach copy of MN Mechanical Bond Concrete and Masonry - $50 Outside Sewer & Water -$50 Excavating/Grading - $50 Siding - $50 Pool Installation - $50 Signs & Billboards - $50 Irrigation System Installation - $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: -�[c Worker's Comp. Insurance Expiration: ct - 22J, - 2- Mechanical Surety Bond ID: jYl G' Mechanical Surety Bond Expiration: l0 -1 i - 21 LEAD ID & Expiration: Date License Issued: I2 m I No. 201(0 — 01-10 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 to 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: Business Address: Zip Code Minnesota Tax Identification No.: 6D Federal Tax Identification No.: 7-- o If a Minnesota Tax Identification number is not required, please explain: 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 licensing 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): �Dr ' com�% Policy Number 7 Dates of Coverage: °I — ZZ22 - OR - I am not required to have Workers' Compensation Insurance because: (check one) I have no employees covered by law; I am self -insured (include permit to self -insure); or Other (specify) I have read and understand my rights and obligations with regards to business licenses, permits and Workers' Compensation coverage and hereby certify by my signature below that to the best of my knowledge, the information provided is true and correct. � Date: �A Signature Printed Name of Signature } itlelPosition 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. a By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of Notary Public. County. My commission expires: FRKJR p[ANGEtate of Mirslic nesotaCommission Expiresanuary 3i 2029 Updated: 01-01-2018 - I CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11 /25/2025 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 endorsement(s). PRODUCER NFP Property & Casualty Services Inc. 1901 Roxborough Road Suite 300 Charlotte NC 28211 COMPLEX RISK PRACTIVE NAIC # INSURER A: The Charter Oak Fire Insurance Company 25615 INSURED CANTPOW-01 INSURER B : Homesite Insurance Company of Florida 11156 Midwest Electric and Generator, LLC INSURERC: Travelers Indemnity Company 25658 10215 Twin Lakes Road NW Elk River, MN 55330 INSURER D : INSURER E' INSURER F : COVERAGES CERTIFICATE NUMBER:212504D777 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 LTRy1rVD TYPEOFINSURANCE rADDL UBft POLICY NUMBER MMIDDNYYY MEFF MVDrYYYY LICY EXP LIMITS C X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [ X OCCUR VTHCO9X648797TIA25 9/26/2025 9/26/2026 EACH OCCURRENCE $1,000,000 PREMISES, Eaoccu"nee $500,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY D�] 4MOT LOC OTHER: GENERAL AGGREGATE $ 2,000.000 PRODUCTS - COMP/OP AGG $2.000,000 $ A AUTOMOBILELIABILITY 1X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY VTC20CAP9X648773COF25 9/26/2025 9/26/2026 Es BlNEDa=danIN L LI $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accldenl $ B UMBRELLA LIAB EXCESS LIAB HX OCCUR CLAIMS -MADE CXP03910701 9/26/2025 9/26/2026 EACH OCCURRENCE $ 5.000.000 X AGGREGATE $ 5,000,000 DED RETENTION $ $ A 'WORKERS COMPENSATION AND EMPLOYERS' LIABILITY AND .ANYPROPRIETOR/PARTNER/EXECUTIVE � OFFICERIM EM BER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A UBB79719282525G 9/26/2025 9/26/2026 ;X ER E. L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000.000 E.L. DISEASE -POLICY LIMIT $ 1.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Evidence of Insurance ua City of Oak Park Heights 14168 Oak Park Blvd N Oak Park Heights MN 55082 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M,V nll ©19BB-2015 ACORD CORPORATION. All rignts reservea. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road N Saint Paul, MN 55155 Midwest Electric and Generator, LLC 10215 Twin Lakes Rd NW Elk River, MN 55330 NOTIFY iIS OF THESE CHANGES TO YOUR BUSINESS. Failure to do so may result in fines. 15-day notice requirement— Farina a Rablea' Il . Change in business' phy'&Pala rr r-2s. Aps,,hoi��ber or email address. . Change in control, owntr5rs, � i3"bers or Biers. • Change in business' legal name and/or assumed name. Loss of orchange in Responsible person, if applicable. Ch'angeAn general liability insurance orworkers' compensation insurance coverage. Licensing and Certification -Services Phone: 651-284-5034 Email: dii.license@state.mn.us Website: www.dif.mn.gov NOTICES N OT TRANSFERABLE IF YOU CHANGE YOUR BUSINESS STRUCTURE, YOU MUST OBTAIN A LICENSE FOR NEW ENTITY WHEN YOU RENEW OR REPLACE INSURANCE POLICY, PLEASE SUBMIT NEW CERTIFICATE OF INSURANCE YOUR CERTIFICATE 15 BELOW THE PERFORATION. SHOW CERTIFICATE WHEN OBTAINING PERMITS. = F; DERARTMENT OF CA CONTRACTOR BOND LABOR AND INDUSTI*- -; � Construction Codes and Licensing Oivistor L¢ensine and Certilication SemiceS. 443 Lafayette Road N St Paul, MN 55155 Website: www,,dli.mn:gov Email dli IlcOts4ttate.m n. 'a Phone G51-284-5034 fhis is to certifi, that the certificate holder is registered as a MECHANICAL CONTRACTOR BOND iifth6 state of Minnesota and is in compliance with Minnesota Statule5 3Z6&197, and has Node $25,000 mechanical bond to perform Sias, htsting, ventilation, cooling, air conditioning, fuel burning, or refrigeration work inpll areas n{the slate dtrnLtg thr registration prriasf. }sit 1det; iGe work pelfprii!zd a-u tires. &Ii the Sute Mechanical Code and the certificate fiu!derrttaii!t kins compI the rcqui red bond and workers camkEgsntwn ias LTCeTISP= MECHANICAI`CC}NT A C?It (.iNI Number:..MS999958 Midwest Electric and Generator, LLC .. Effective date: 08/25/2025 ' 10215 Twin Lakes Rd NW Expiration date: 10/17/2027 - Elk River, MN 55330