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Home My WebLink AboutAssociated Mechanical Contractors 26-21CONTRACTOR 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: ASSOCIATED MECHANICAL CONTR., INC. Address: MN Telephone: Fax: (4S y ) `(w5- - r i i E-mail rnl ensk�4=(R 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 I),&2--7 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: — — Worker's Comp. Insurance Expiration: rj=L- 2j)2 Mechanical Surety Bond ID: 00 --,�a 0(a Mechanical Surety Bond Expiration: -� 0 LEAD ID & Expiration: Date License Issued: No. 2IL3 --� 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: ASSOCIATED MECHANICAL CONTR., INC. Business Address: SHAKOPEE MN 55379 City State Zip Code Minnesota Tax Identification No.: i-57371 l Federal Tax Identification No.: L+ 1— 13 a s 14l If a Minnesota Tax Identification number is not required, please explain: Date: n 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 tV the licensing a-gency 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 Policy Number Dates of Coverage: - OR - not the Insurance Agent): EMC. Acz:4-0 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 orkers' Compensation coverage and hereby certify by my signature below that to the b t of my knowledge, the information provided isf true and correct. Date: ignatu e Printed Nam of Signature FCC Title/Position of Person Signing Z! 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. By. Date ' CorpAratecer r lndivi Proprietorship Owner Subscribed and sworn to before me this day of I p C�-�. Notary Public. County. My commission expires: 61 I.;tozo WIRY K LEMKE E9(MVf*""*N10n NOTARY PUBLICMINNESOTA ExpirBs Jsn. 31. 2 330 Updated: 01-01-201 S MDEPARTMENT OP LABOR AND INDUSTRY Construction Codes and licensing Di4isfon W,ebsite, w.ww.tflLmngov MECHANICAL CONTRACTOR BOND Llcensing and Certification Servlces 443,!.Ayette RogdM St. Paul,.MN 55155 Email: dil.i1censeP,1tate.mn.ui Phone: 651-284.5034 This is to certify that the certificaie holder is rcgiswred as aMECI-1A:NICA1r.CONTRACTOR BOND In the state of Mitiriesota-and is in compliance_with Minnesota Statutes 326BA07, and hits, Fled. a $25.000 mechanical bond to per€urns gas, heating, vtnlilativn, couiitsg. air conditioning, fuel burning, or refrigeration w0tk in al"reas of the state during the registration period; provided.the work perforrned.complics with the State Mechanical Code and. the certificate holder maintains compliance with the required bond and workers' compensation laws. License: MECHANICAL CONTRACTOR 13OND Number: MB003206 Associated Mechanical Contractors -Inc Effectivetlate: 701/2024 PO Box 237 Expiration date: 8/15/2026 Shakopee .MN 55379-0237 ^ , 0 DATE (MMIDD/YYY1) aJ)?" CERTIFICATE OF LIABILITY INSURANCE 7/1/2025 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 NAM acr Frank Rutkowski Holmes Murphy & Associates PH NE 612�4g 2431 FAX a _ 2727 Grand Prairie Parkway rAfE-MA<L Waukee IA 50263 ADDRESS: ftutkowski@holmesmurphy.com INSURERISI AFFORDING COVERAGE NAIC 0 INSURED Associated Mechanical Contractors Inc 1257 Marschall Rd Shakopee, MN 55379 /+C�T1 CIe ATC \111&A0C0.194GG7A79G INSURER A. Hanover Insurance Company22292 INSURER B : Pacific Insurance Company, Limited 10046 INSURER C: Employers Mutual Casualty CompanyCompagy 21415 INSURER D: EMCASCO Insurance Company 21407 INSURER E : Homesite Insurance company of Florida 11156 INSURER F RFVISIr1N1 NI IMRFR- 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 q SUBR POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER iMMJPDNyYy1 CMWDDIYYYyl D X COMMERCIAL GENERAL LIABILITY BBB0127 7/1/2025 7/1/2026 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTE PREMISES £a occurrence $ 1,000,000 X MED EXP (Any one person) $ 10.000 Contr Liab Per X Policy Fom1/XCU PERSONAL & ADV INJURY $ 1.000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 ' POLICY jE D LOC Deductible $10,000 OTHER: C AUTOMOBILE LIABILITY 6N46355 7/1/2025 7/1/2026 COaBINFDSINGLE LIMTT fEa.X $1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) ' $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED P @OPaERdTY pAMAGE $ AUTOS ONLY AUTOS ONLY Hired Auto Ph s Dm a $100,000 X comp-1.0X - O0 C X UMBRELLA LIAR X OCCUR 6,146355 7/1/2025 7/1/2026 EACH OCCURRENCE $10.000.000 E CXPOS401900 7/1/2025 7/1/2026 X AGGREGATE $10,000,000 EXCESS LIAB CLAIMS -MADE DED I X RETENTION $ $ D WORKERS COMPENSATION 6H46355 7/1/2025 7/1/2026 X $7ATUT ER AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1.000,000 OFFICERIMEMBER EXCLU DED? N] (Mandatory In NH) NIA E.L. DISEASE- POLICY LIMIT $ 1,000.000 If yes, describe under DESCRIPTION OF OPERATIONS below A Insll Fltr-Completed Value RHXA813072 7/1/2025 7I112026 SP6cl*Form Limit: $1.000,000 B Professional Liability 83CPIEB3621 7/1I2025 7/1/2026 EaACL$S.006,000 Ea Cond:$5,000,000 Pollution Liability TILES Ea Incident: $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHIC (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ALL WORK PERFORMED /-CoTICrr•ATC url{ 11r-D 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 14168 Oak Park Blvd N AUT RIZEDREPRESENTATIVE Stillwater MN 55082-6476 V ltltftf-ZUTDAL,UKU L,UKYUKAI IUIY. M11 nyms rCSC1vCU. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD