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HomeMy WebLinkAboutMP Nexlevel LLC 26-25 a r= any 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)439-4439—FAX:(651)439-0574 Email:jhultman@cityofoakparkheights.com Business Name: MP Nexlevel, LLC Address: 500 County Rd 37 E Maple Lake MN 55358 Telephone: (320 ) 963-2400 Fax: ( ) E-mail mpnl-all-contractsdepu mpnexlevel.us 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 x 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: 12 3 -2-co Worker's Comp. Insurance Expiration: 2--3I —2 J , Mechanical Surety Bond ID: Mechanical Surety Bond Expiration: LEAD ID & Expiration: Date License Issued: /— )( -Z co _No. 2 W 2 6 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: MP Nexlevel, LLC Business Address: 500 County Rd 37 E Maple Lake MN 55358 City State Zip Code Minnesota Tax Identification No.: 6011087 Federal Tax Identification No.: 30-0095149 If a Minnesota Tax Identification number is not required, please explain: Date: 1ni202e Signature: --e 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): Zurich American Insurance Company Policy Number WC-8902941-06 Dates of Coverage: 12/31/2025-12/31/2026 - 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 the best of my knowledge the i.formation provided is true and correct. Date: 1/7/2026 Signature Robbi L. Pribyl Printed Name of Signature President Title/Position of Person Signing 7 Li \ Pi 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. 11 I2fo By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this day of , — t 11 SAMANTHA O'DOWD Q ^' NOTARY PUBLIC , Notary Public. MINNESOTA W �Y cmi— County. ;; s' My Commission Expires Jan.31,2028 My commission diI(pires: joinuavy 31S}, ,,ZOaS Updated:01-01-2018 � l Page 1 of 1 A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 12/18/2025 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 CONTACT WTW Certificate Center NAME: Willis Towers Watson Midwest, Inc. PHONE c/o 26 Century Blvd (A/C No.Ext): 1-877-945-7378 FAX No): 1-888-467-2378 E-MAIL certificates@wtwco.com P.O. Box 305191 ADDRESS: Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Zurich American Insurance Company 16535 INSURED INSURERS: AXIS Surplus Insurance Company 26620 MP Nexlevel, LLC 500 County Road 37 East INSURER C: - - Maple Lake, MN 55358 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W42844049 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DDNYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 4,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 4,000,000 PREMISES(Ea occurrence) $ A X Contractual Liability MED EXP(Any one person) $ 10,000 GLO 8902940-06 12/31/2025 12/31/2026 PERSONAL BADVINJURY $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 8,000,000 POLICY X PRO LOG PRODUCTS-COMPIOPAGG $ 8,000,000 PRO- JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 5,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 1C HAP 8488453-06 12/31/2025 12/31/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE _ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 B — X EXCESSLIAB CLAIMS-MADE P-001-000068228-07 12/31/2024 06/30/2026 AGGREGATE $ 5,000,000 DED RETENTION$ $ WORKERS COMPENSATION X MUTE EMPLOYERS'LIABILITY STATUTE ER Y/N A ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 5,000,000 OFFICER/MEMBER EXCLUDED? No N/A WC 8902941-06 12/31/2025 12/31/2026 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE__ $ 5,000,000 If yes,describe under 5,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Workers Compensation/ WC 8713291-06 12/31/2025 12/31/2026 E.L. Each Accident $5,000,000 Employers Liability E.L. Disease-Ea Empl $5,000,000 Per Statute E.L. Disease-Pol Lmt $5,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Oak Park Heights is included as an Additional Insured as respects to General Liability and Auto Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oak Park Heights AUTHORIZED REPRESENTATIVE 14168 Oak Park Blvd. N Oak Park Heights, MN 55082 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 29066205 BATCH: 4248692