Loading...
HomeMy WebLinkAboutNorthland Fence 26-05CONTRACTOR 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: ihultman@cityofoakparkheights.com Business Name: Northland Fence Address: 6390 McKinley St NW, Suite 150 Ramsey MIS1,55903 Telephone: ( 763 ) 237-6391 E-mail installs@northlandfence.com Fax: ( 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 volic . • 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 arovided continued proof of insurance coverage_ LICENSE CLASSIFICATIONS: Commercial General Contractor - $50 Blacktopping - $50 Heating, Ventilation & A/C - $50 Fence Installation x g -$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: 3 - 1 3- Z 6 Worker's Comp. Insurance Expiration: Mechanical Surety Bond ID: Mechanical Surety Bond Expiration: LEAD ID & Expiration: 1 Date License Issued: 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: Patrick Quinn Applicant's Address. 6065 156th Lane NW Ramsey MN 55303 city Social Security No.: 469-93-0691 State Zip Code Business Information: (Complete only if applicable) Business Name: Northland Fence Business Address: 6390 McKinley St NW, Suite 150 City MN 55303 State Zip Code Minnesota Tax Identification No.: 4007720 Federal Tax Identification No.: 74-3789082 If a Minnesota Tax Identification number is not required, please explain: Date: 12r4i2025 Signature: Title: n.m, 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): Policy Number WC 9135642 Dates of Coverage: 3/13/2025-3/13/2026 - OR - Selective Insurance Co 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) ['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 thZ!p the best of my knowledge, the information provided is true and correct. Date: 12/4/2025 Signature Patrick Quinn Printed Name of Signature Owner Title/Position of Person Signing 9-5 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. 12/4/2025 By: Patrick Quinn Date Corporate Officer or Individual Proprietorship Owner Subscri d and sworn to befo a me this day of e Notary Public. _cif Qi County. My commission expires: -3 Updated: 01-01-2018 BRITTANY ARIEL KELSAY NOTARY Pt19LIC MlNlVESOTR 1A'129SMY COMMio EXPIRES 0 AC R a DATE (MMIDD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 12/03I2025 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 Insurance Brokers of MN, Inc. 3351 Round Lake Blvd Anoka MN 55303 NAM£ Insurance Department PHONE 6tt (763) 323-3000 me No (763) 323-8353 AfC Ho EMAIL insbmkersmn@insurancebrokersmn.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC p INSURERA: Selective Insurance Company ofAmeriac 12572 INSURED NORTHLAND FENCE MINNESOTA LLC NORTHLAND CONSTRUCTION AND FENCE LLC 6065 158TH LN NW RAMSEY MN 55303-4136 INSURER B : INSURER C : INSURER D : INSURER E INSURER F : rf% 1C0A(_Cc (_FRTIFI(`ATF NIIMRFR• 2025-2U26 V2 REVISION NUMBER: THIS IS TO CERTIFY THAT THE PCLiCiES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 tLTR TYPE OF INSURANCE ALMLIbUDKI INSD WVD POLICY NUMBER POLICY EY MMIDD MMOWYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR DAMTk9r. TO FEN PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 15,000 A S 2552372 03/13/2025 03/13/2026 PERSONAL B ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY 19 JEC El LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED NGI..E LlMiT Ea accideh! $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY(Peraccident) $ AOWNED IANYAUTO SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY S 2552372 03/13/2025 03/13/2026 PROPERTY DAMAGE Per amden $ Uninsured motorist $ 1,000,000 X UMBRELLA LIAR OCCUR V� z6� F V'��y'V E..... EACH OCCURRENCE $ 10,000,000 A EXCESS LIAR CLAIMS -MADE S 2552372 03/13/2025 03/13/2026 AGGREGATE $ 10,000,000 DED I I RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIR/PARTNER/EXECUTIVE OFFICER/MEMBMB ER EXCLUDED? ❑ (Mandatory in NH) NIA WC 9135642 03/13I2025 03/13I2026 PER OTH- STATUTE ER E L EACH ACCIDENT 1,000,000 $ E L DISEASE- EA EMPLOYEE $ 1,000,000 E L. DISEASE - POLICY LIMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) r-Lc-rrclrATc unI nca CAN('FI I ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oak Park Heights ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd N. AUTHORIZED REPRESENTATIVE Oak Park Heights MN 55082 404 __zz2_ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD