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HomeMy WebLinkAboutIndigo Sign 26-08CONTRACTOR 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: Indigo Signworks, Inc DBA Indigo Signs Address: 4133 Iowa Street suite 100 -Alexandria MN 56308 Telephone: ( 320) 391-4946 Fax: ( ) E-mail kim.feldewerd@indigosigns.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 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 rovided 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 ** Attach 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. Office Use Only: Liability Insurance Expiration: 1( ,1 b _ D1_ Worker's Comp. Insurance Expiration: Mechanical Surety Bond ID: Mechanical Surety Bond Expiration: LEAD ID & Expiration: "r Date License Issued: No. 9,6_ Us 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 State Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: Indigo Signworks, Inc DBA Indigo Signs Business Address: 4133 Iowa Street Suite 100 Alexandria MN 56308 City State Zip Code Minnesota Tax Identification No.: 3324380 Federal Tax Identification No.: 45-0444969 If a Minnesota Tax Identification number is not required, please explain: Date: 11/18/24 Signature:40"W-� r Title: 5unoort ■eoi2 t 1 P[dL Manager 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 7094854227 Dates of Coverage: 11/18/25 - 11/18/26 - OR - The Continental Insurance Company 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. X"A. yzg�L�—g Date: 12/3/25 SEg atu Kim Feldewerd Printed Name of Signature Support Specialist / Project Manager 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. Date By: Corporate Offic ndividual Proprietorship Owner Subscribgd and sworn to before me this Firn day of nVVI Notary Public. _ County. My commission expires: -Sox 31 0)-j r•� BRANDY STARP SCHMIDT traTARY F°UBLIC MINNESOTA T �tV Commission Exons JIM 31.2027 Updated: 01-01-2018 Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road N Saint Paul, MN 55155 NOTICES NOT 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 Licensing and Certiflcatton Services Phone: 651-284-5034 Email: dll.license@state.mn.us Website: www.dli.mn.gov- INDIGO SIGNWORKS INC PO BOX 1476 FARGO, ND 58107 NOTIFY US OF THESE C14ANGES TO YOUR. BUSINESS; = . Failure to-do so may result 1n fines. 15-day notice tequfrernent—Fpiiis iTBlia leafslllmifgav Change.in business h-slcai,adt€ress ihalliri adOiess Wieinumber or email address. • Change in control, arHrieis=cfftcera di're'itar ;Frsero ers c i partners. * Change In business':legal name and/or assumed name. Loss of or change in Responsible Individual ■ Change in generatiiability_insurance orworkers' compensation insurance coverage, i �� _ of :- - __ -_ _ �f �_Y.-•. _��- . _ _ - YOUR CERTIFICATE IS BELOW THE PERFORATION. SHOW CERTIFICATE WHEN.OBTAINING.PERMRS.. DFPARTAiE,NT OF LABOR AND INDl1ST R_IGNGCNTRACTOR BOND -- Canstniellart Codes and lkenstng plvlsSoFl Licensing and CerU fltaFion.5ervlces 443. tarayette noad.N St. Paul, MN 55155 Website: wwwAll.mmov Finall: dll.gtense@stale.n:n.vs Phone:. 6S1-244-5034 This is to certify. tlzal the certificate holder is registered as a SIGN CONTRACTOR ]3aN[]an the s!ale.orMinnesola and is in s ompliancc �yith Minnesara.S.latutes 32613.865, and has tileda S8,000.sign contraeters frond to perronn duties.and.comply with laws, ordinances, rules and COO racis entered into for the installation of skk@jn aitaf s—of llmstatc_during the registration period; provided Ilse cgrdTcalc hofder.maintains compliance Yi[fi'the_ _f_dNO- i_.3._an"� �'laws, - License ; StGN CONTRACTOR BOND Lic Number: SB683135 INDIGO SIGNWORK5 ING ' I Effective 0512?J2!)24 PO BOX 1476 IB Expiration date: 05/21/2026 FARGO, ND 58107 T J. 7 0 DATE (MM/DDIYYY ) Acon RCERTIFICATE OF LIABILITY INSURANCE k�. 11/18/2025 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 1040ASMITe T Lily Chau or Nicole Borstner Sample Producer INC- N o. . (612)333-3323 FAQ o : (612) 373-7270 123 Main Street Iff4mit. Nicole.Borstner@bbrown.com Amherst. MA 01002 INSURED Indigo Signs, Inc. 1622 Main Avenue Fargo, ND 58103 INSURERS AFFORDING COVERAGE NAIC # A, The Continental Insurance Company 35289 B : National Fire Insurance Company of Hartford 20478 C: D: E: F: r,rt%1r_PAr_1FC r_FRTIFIrATP NIIIMRPR• Qn9399 RFvi,;lnN NIIMRFR- 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. IN5R ADOL SUER POLICY EFF POLICY EXP LIMITS I_TR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE IX-1OCCURPREM1 $ 500,000 DAMAGE NIM— SUApn MED EXP (Any one person) $ 15,000 A 7094854213 11-18-2025 11-18-2026 PERSONAL BADVINJURY $ 1,000,000 GENLAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT Fx_1 LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Me aC;q_4P0t1 $ 1,000,000 ANYAUTO BODILY INJURY (Per person) $ A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY 7094854180 11-18-2025 11-18-2026 BODILY INJURY (Per accident) $ PROPE9 1,IAMAGE P c ' $ $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE 7094854194 11-18-2025 11-18-2026 DEO I X I RETENTION $ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED7 � (Mandatory In NH) N/A 7094854227 11-18-2025 11-18-2026 X TATllTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below I A Property 7094854213 11-18-2025 11-18-2026 Business Pers. Prop. ' 6,806,081 Business Income/EE 6,665,300 Building 6.266,251 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) Evidence of Insurance. rForlClreTF uni nFR rANrFI I ATICIN 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. Oak Park Heights, MN 55082 AUTHORIZED REPRESENTATIVE f)04— /L "t__ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD