Loading...
HomeMy WebLinkAboutHarris St. Paul 26-15�u 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: Harris St. Paul. Inc. Address- 909 Montreal Cir, St. Paul, MN 55102 Telephone: (651 ) 602-6500 E-mail licensing@harriscompany.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 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: 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 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: Worker's Comp. Insurance Expiration: -� - Mechanical Surety Bond ID: �) 05a Co_ Mechanical Surety Bond Expiration: [ -_�U -,7 LEAD ID & Expiration: — Date License Issued: 1 0-191 No. 2t045 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: Harris St. Paul Inc. Business Address: 909 Montreal Cir, St. Paul, MN 55102 city State Zip Code Minnesota Tax Identification No.: 4643078 Federal Tax Identification No.: 41-1447328 If a Minnesota Tax Identification number is not required, please explain: Date: 12/11/24 Signature: 5$ Title: Licert9fig and Safety Coordinate im- 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 WC011030804 Dates of Coverage: 04.01.2024-04.01.2025 - OR - Zurich American 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. Q"- Date: 12/11/24 nature Jessica Boliig Printed Name of Signature Licensing and Safety Coordinator Title/Position of Person Signing al 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. 12111/24 Date f� By: Corporate Officer or In ividual Proprietorship Owner Subscribed and sworn to before me this 11th day of December 2024 Notary Public. County. My commission expires: 1-31-2029 Updated: 01-01-2018 7JESSICA ANN BOLLIGb!€c-MinnesotaI!fVVV'VVVVVVV0"I� Expires Jan. 31. 2929 I 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 Certification Services Phone: - 651-284-5034 Email: dii.license@state.mn.us Website: www.dii.mn.gov HARRIS ST PAUL INC 909 MONTREAL CIRCLE ST PAUL, MN 55102 NOTIFY US OF THESE CHANGES TO YOUR BUSINESS.r Failure to do so may result in fines. 15-day notice requirement— Forms available atAll.mn.gov. Ate- Change in business' physical. address, mailing address, phone number or email address. • Change in control, owners; officers, directors, members or partners.'R``= Change in business' legal name and/or assumed name. • Loss of or change in Responsible Individual e Change in general liability insurance or workers' compensation insurance coverage. �w s YOUR CERTIFICATE IS BELOW THE PERFORATION. MDEPARTMENT OF LABOR AND INDUSTRY Construction Codes and Licensing Division Webslte: wwwAlLmn gov SHOW CERTIFICATE WHEN OBTAINING PERMITS. MECHANICAL CONTRACTOR BOND Licensing and Certirication,5ervices 443 Lafayette Road N 5t. Paul, MN 55155 Email: dll.11cense@state:mn.us ' Phone: 651-284-5034 This is to certify that the certificate holder is registered as a MECHANICAL CONTRACTOR BOND in the state of Minnesota and is in compliance with Minnesota Statutes 32613.197, and has filed a $25,000 mechanical bond to perform gas, heating, ventilation, cooling, air conditioning, fuel burning, or refrigeration work in all areas of the state during the registration period; provided the work performed complies with_ the State Mechanical Code and the certificate holder maintains compliance with the required bond and workers' cotnpensa6on laws. 5„2: Y' L' Registration MECHANICAL CONTRACTOR BOND RegNumber: MB005265 HARRIS ST PAUL INC�1y s Effective date: 05/22/2024 909 MONTREAL CIRCLE w L Expiration date: 06/30/2026 ST PAUL, MN 55102 = -r,. `-��y-T ,.,.zw .:��y �' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3/28/2025 , rIIS 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 hol g in licu.4such endorsemen sj: PRODUCER n R s-c b t� (i f" r� CONTACT Holmes Murphy & Associates �'`�`�` -� '° `" PHONE Frank Rutkowski 2727 Grand Prairie Parkway 612-349-2431 Nc.No: Waukee IA 50263 6-MAIL ,ss.. futkowski holmesmur h ,com t 2025 INSUfWA AFFORQ)mGCOVERAGE NAiCe )NSURERA: Starr Indemnity & Liablii Comparty 38318 INSURED f� ONEINC 1 INSURER B: National Union Fire Ins- Co. Pittsbur h 19445 Harris St Paul, Inc Cite of Oak Park Heights 909 Montreal Circle INsuReRc: St Paul, MN 55102 - - AID INSURER D PM -- —• — — INSURER E INSURER F: 6C Vlrin hl wli Ie1QC12- 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. _____ WSW TYPE OF INSURANCE jAi70L�SUBRII POLICY EFF T PRLICY EXP r' LIMITS LTR IN50 WV 1 POLICYNUIVER MWDDIYYY MMIlDDIYYY B X COMMERCIAL GENERAL LIABILITY GL5489472 4/1/2025 411/2026 EACH OCCURRENCE $2.000.000 ` r— I CLAIMS -MADE i X II OCCUR j AMAGE TO RENTED ,ARE S5E5 aocaure Ce�,$300,000 X Contr Lab Per j MED EXP iAny oneperson) $ 10,000 l PERSONAL 8 ADV INJURY 1 52000.000 X Policy Form/XCU - GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X LOC I I PRODUCTS • COMP1UP AGG S4.0013,006 $ B OTHER: AUTOMOBILE LIABILITY CA5309747 411/2025 4/1/2026 COMBINED SiNGLE LIMIT s2,000.000 X ANY AUTO - BODILY INJURY (Per person) $ OWNED �� SCHEDULED I BODILY INJURY (Per accident)' $ AUTOS ONLY I��'r��xx� AUTOS NON-OWNEDP1111; X HIREDAUTOS 4 ITYQAAAAGE $ ONLY I .. AUTOS ONLY A UMBRELLA LIAB X OCCUR 1000588320251 I 4/112025 41112026 EACH OCCURRENCE $ 5,000.000 AGGREGATE $ 5,000.000 X EXCESS LIAB CLAIMS -MADE DEDf X RETENTION $ $ B WORKERS COMPENSATION VVC87087504 4/1/2025 4/1/2026 X ERTUTE ESP B I ANYPRDPRIETOAIPAFrrNr:RIEXECUTIVE Y / N i WC87087506 4/112025 4/1/2026 I E.L. EACH ACCIDENT $ 1,002,000 E. L. DISEASE - EA EMPLOYEE _ $1,000,000 B i OFriCERMIEMBEREXCLUDED? (Mandel cry In NH) N/ A { WC87087507 4/1/2025 I 4/1/2026 E i E.L. DISEASE -POLICY LIMIT $ 1,000,000 II yes, describe under DESCRIPTION OF OPERATIONS below B Stop Gap Liability WC87087504 4/1/2025 411/2026 'Applies to states. ND, OH, WA, VVY � I DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be atlached If more space Is required) LICENSE/PERMIT REQUIREMENTS ADDITIONAL INSURED ONLY IF REQUIRED BY WRITTEN CONTRACT WITH RESPECT TO GENERAL LIABILITY: CITY OF OAK PARK HEIGHTS TE HOLDER u 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 AUT RIZEDVEPRESENTATWE STILLWATER MN 55082-6476 ACORD 25 (2016/03) bftwomm.— ©1988-2015 ACyyORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7482: 2 - of