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HomeMy WebLinkAboutGCM Construction 26-064A CONTRACTOR LICENSE APPLICA 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: GCM Construction Address 2201 107th Lane NE Blaine MN 55449 Telephone: ( 763) 862-0005 Fax: E-mail aaustin(a)acmcompanies.com 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 palicy. • 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: Blacktopping - $50 Building Moving -$50 Concrete and Masonry - $50 Excavating/Grading - $50 Pool Installation - $50 Irrigation System Installation - $50 X 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: (O Worker's Comp. Insurance Expiration: _ 4, Mechanical Surety Bond ID: -- Mechanical Surety Bond Expiration: l LEAD ID & Expiration: Date License Issued: No. 2G _ 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. General Contractors of Minnesota, Inc DBA: GCM Construction Business Address: 2201 107th Lane NE _ffiai e MN 55A49 City Slate Zip Code Minnesota Tax Identification No.: 78-97262 Federal Tax Identification No.: 20-3161393 If a Minnesota Tax Identification number is not required, please explain; Date: 12/8/2025 Signature: Title: President 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): Selective Insurance Group Policy Number WC 9141131 Dates of Coverage: 6/9/2025 - 6/9/2026 - 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 th best of nowledge, the information provided is true and correct. Date: 12/8/2025 Signatu Grea Austin Printed Name of Signature President 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 By: Date Corpor4jig Ofi er or Individual Proprietorship Owner Subscribed and sworn to before me this r' day of —toss` C�^'�"^�- , Notary Public. ..¢— County. My commission expires: alter 3 wz9 Updated: 01-01-2018 RIMMAD. MEDELSERG Notary public Minnesota MyComrnft EOM JAN.31, 2M GENECON-01 ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYYY) 12/8/2025 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(les) 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 NAA�EAc'r Matthew Sundeen, CIC, AAl 1Riguilro9700a Agency WC, N , Exit): (651) 636-2750 FAX No):(651) 638-9762 IS Dakcrest Avenue. Suite 300 Roseville, MN 55113 Moss; msundeen@maguireagency.com INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: Selective Insurance Group Inc ,12672 INSURED INSURER B : General Contractors of Minnesota, Inc. DBA GCM Construction INSURERC: 2201 107th LN NE INSURER D : Blaine, MN 55449 INSURERE: INSURER F : COVERAGES CERTIFICATrz NUMBER. EVISi 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 CONTRACTOR 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•ADDL . TYPE OF WSU RANCE SD ;n POLICY NUMBER PO,CYEFF 1POUCTEXP J LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS -MADE I X I OCCUR X X ;S 2726986 6/9/2025 619/2026 DAMAGETO(Ce NToccDnce) S 500,000 15,000 MED FXP (Any one person) 5 1,000,000 PERSONAL & ADV INJURY $ 2,000,000 0_E_iWL AGMECA LIMIT APPLIES PER: GENERAL AGGREGATE S C 2,000,000 POLICY LSiJ JECT LOC PRODUCTS - COMP/OPAGG _ S OTHER!_ 5 A COMaI SING! C LIMIT AUTOMOBILE LIABILITY Ea acuNE] {dnnT) 5 X ANY AUTO S 2726986 6/9/2025 619/2026 BODILY_ INJURY (Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per.acciden(), 5 AS ONLY NON-OWNED HIRED TSO ONLY � PERTY iAMAGE Peracadl $ A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE .5 8,000,00D EXCESSLIAR CLAIMS -MADE S 2726986 6/9/2025 6/912026 AGGREGATE $ 8,000,000 S[ 0 DEC) A RETENTIONS A WORKERS COMPENSATION X ❑TH' E Ett AND EMPLO"RV LIAOLITY YIN 'WC 9141131 - . - 6/9/2025 6/9/2026 .ACH 1,000,000• QQANNFY CPROPRIETOR/PARTNER/EXECUTIVE [ei*FIIJERIME NHREXCLUDED� NIA - A E L..EACH ACCIDJJT S EA. DISEASE- EA EMPLOYEE 5 1,000.000 IF RBA, describe under 1.000,000 :DESCRIPTION OF OPERATiaptS oelow , E L- DISEASE - POUdCY LIMP S DESCRIPTION of OPERATIONS /LOCATIONS I VEHICLES (ACOnD 101, Additional Remarks Schedule, may be altNOoG 11 monk *Paco Is required) City of Oak Park Heights is a General Liability Additional Insured as required by written contract per farm CG 73 00 10 23 attached. CERTIFICATE HOLDER _ _ CANCELLATION. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Oak Park Heights Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Boulevard N. Oak Park Heights, MN 55082 — AUTHORIZED REPRESENTATIVE I ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD