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HomeMy WebLinkAboutSpectrum Sign Systems Inc 26-04IQ 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) 4394439 - FAX: (651) 439-0574 Email: jhultman@cityofoakparkheights.com Business Name: Spectrum Sign Systems Address: 8786 West 35W Service Drive NE, Blaine MN 55449 Telephone: C63 )432-7447 E-mail Mary@spectrum-signs.com Fax: (163 ) . ZOOI— I IS 1 — 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 polic . • 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. • 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: 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 ** Affach copy of MN Mechanical Bond Outside Sewer & Water -$50 Siding - $50 x 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. pb Office Use Only: Liability Insurance Expiration.- �1- 21-, Worker's Comp. Insurance Expiration: S-2-2 �� -�2 -2_�) Mechanical Surety Bond ID: -- Mechanical Surety Bond Expiration: — LEAD ID & Expiration: Date License Issued: I No. 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: Mary Ferraro Applicant's Address: 861 Fox cove Lino Lakes MN City Social Security No.: State Business Information: (Complete only if applicable) Business Name: Spectrum Sign Systems Business Address: 8786 West 35W Service Drive NE Blaine City MN State Minnesota Tax Identification No.: 5398377 Federal Tax Identification No.: 41-2005680 If a Minnesota Tax Identification number is not required, please explain: Date: Signature: Title: Ofice Manager f 55014 Zip Code 55449 Zip Code 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 Compan. Policy Number _ Dates of Coverage: !se]V (not the Insurance Agent): S—OCA11-�Si�-Ys 03 �Z 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: Sig g ture 0 J Printed Name of Signature LIbLe-1 ,010*7&, afb 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. � z Ire I Z, Date By:/ Co orate Officer or Individual Proprietorship Owner Subsc+ i:,ed and sworn to befor me this �L� day of —. L� Notary Public. County. My co mission expires: 2_g Updated: 01-01-2018 AcaRio� CERTIFICATE OF LIABILITY INSURANCE DATE(Mos/z2//2025 Y) ozs 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 North Risk Partners P.O. Box 64016 St Paul MN 55164 CONTACT Becky Christianson NAME: N� (763) 536-8006 rAX PHONE JAIjAfC, M1ol: FIL ADDRESS: becky.christianson@northriskpartners.com INSURER S) AFFORDING COVERAGE NAIC # INSURERA: Secura Insurance Co 22543 INSURED Spectrum Sign Systems, Inc 8786 West 35W Service Drive Blaine MN 55449 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : rnvaRer:Fc rPPTiFICATF NtIMRF;R' 25/26 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. TNSR t7R TYPEOFINSURANCE INSD WVD POLICY NUMBER MMDDY/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE500.000 PREMISES Eaoxurreaca $ MED EXP (Any oneperson) $ 10,D00 Contractual Liability A X XCU CP3222934 05/24/2025 05/24/2026 PERSONAL& ADV INJURY $ 1,000,000 GEN'L.AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY Eg PRO- ❑ LOC JECT OTHER: AUTOMOBILE LIABILITY COMBINED ING I Ea a dent $ 1,ODO,000 BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (Per accident) S A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY JX A3222935 05/24/2025 05/24/2026 PROPERTY DAMAGE Per acpdem $ S X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESSLIAa M CLAIMS -MADE CU3222937 05/24/2025 05/24/2026 AGGREGATE $ 5.000,000 DED I X1 RETENTION S 10,000 $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA WC3222936 05/24/2025 05/24/2026 X SEAT UTE ERH EL. EACH ACCIDENT 1,000,000 S EL. DISEASE- EA EMPLOYEE 1 000000 $ ,, E.L. DISEASE- POLICY LIMIT S 1.000,000 If yes, describe under DESCRIPTION OF OPERATIONS below Equipment Leased or A Commercial Inland Marine CP3222934 05124/2025 05/24I2026 Rented from Others 25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights 14168 Oak Park Blvd No 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 © 1983-2015 ACORD GORPORATION. All rights reserveo. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD MDEPARTMENT OF LABOR AND INDUSTRY Construction Codes and Licensing Division Website: www.dli.mn gov SIGN CONTRACTOR BOND Licensing and Certification Services "3 Lafayette Road N St Paul, MN 55155 Email: dli.license@state.mn.us Phone- 651-284-5034 This is to certify that the certificate holder is registered as a SIGN CONTRACTOR BOND in the state of Minnesota and is in compliance with Minnesota Statutes 326B.865, and has filed a $8,000 sign contractors bond to perform duties. and comply with laws, ordinances, rules and contracts enteredr into for the installation of signs in all areas of the state during the registration period; provided the certificate holder maintains compliance with the -required bond and workers' compensation laws. License: SIGN CONTRACTOR BOND Number. SB686046 Spectrum Sign Systems Inc Effective date: 9/13/2024 8786 W 35W Service Dr NE Expiration date: 9/12/2026 Blaine MN 55449-6787