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HomeMy WebLinkAboutMajor Mechanical LLC 26-20CONTRACTOR 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: MAJOR MECHANICAL LLC Address: 7601 NORTHLAND DR N SUITE 110 BROOKLYN PARK MN 55428 Telephone: C63 ) 424.6680 E-mail SONJIA@MAJORMECH.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 polic . • 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 k�( - 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 - -2UZ Worker's Comp. Insurance Expiration: - Mechanical Surety Bond ID: Mechanical Surety Bond Expiration: 1 �. Z LEAD ID & Expiration: Date License Issued: No. 2 2 D 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: MAJOR MECHANICAL LLC Business Address: 7601 NORTHLAND DRIVE N SUITE 110 BROOKLYN PARK MN 55428 City State Zip Code Minnesota Tax Identification No.: 3780527 Federal Tax Identification No.: 41-1567467 If a Minnesota Tax Identification number is not required, please explain: _._ ' Y1i. raz 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 bV 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 100001595/EWC010188 Dates of Coverage: 01/01/2026 - 01/01/2027 - OR TBG 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 m ledge, the information provided is true and correct. Date: Z � 2-(,, Sianature Printed Name of Sig ture Title/Position of Person Signing 6Z 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 Corpor a Officer or Individual Proprietorship Owner -- Subscribed and swor to before me this nol day of ac�l„ �o Notary Public. ILI s,, County. My Caj,_ • Sonjia M. Wagner NOTARY PUBLIC MINNESOTA E.- 1P �y.. .My Commission F� nsJan. 31, 2030 Updated: 01-01-2018 Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road N Saint Paul, MN 55155 Major Mechanical LLC 7601 Northland, Dr N Ste 110 Brooklyn Park, MN 55428 .XY $AfTHE-I ANGES TO YOUR BUSINESS. Failure to..do sb. may result In fines. Licensing and Certification Services Phone: 651-284-5034 Email: cili.license@state.mn.us, Website: www.dll.mn.gov L NOTICES NOTTRANSFERABtE IF YOU CHANGE YOUR BUSINESS STRUCTURE, YOU MUST OBTAIN A LICENSE FOR NEW ENTITY WHEN YOU RENEW OR REPLACE INSURANCE POLICY, PLEASE SUBMIT NEW CERTIFICATE OF INSURANCE 15-day notice requirement — Formkavailable at dliimn.gov. Change In business' physical address, mailing address, phone number or email address. Change in control, owners, officers, directors, members.or partners. h tla g�inffli m`eu* legal name and/or assumed name. z - RlFassgli'or ka:n&7 Responsible person, If applicable.- W In� liablllty Insurance or workers ViT. compensain can�ag� .s �` + '1 OUR CERTIF'1 ATE IS BELt7W THE PERFORATION. 1 i + ie - 'SHOW CEOFICATE WHEN OBTAINING PERMITS. LA B O RTMENT A N D I H D U S T.R,Y. MECHANICAL. CONTRACTOR BOND i i e - C� S �d Licensing Division_ LI[ennd Certi[k rv� Laravatte Read N St. Paul, MN 55155 +ram �tnle Lim- Ali.mnguv E �3+1}[eh� a eatn� Pt+one: 651-284-5034 4 = ��$ This is to certify that the certificate holder is registered as a MECHANICAL CONTRACTOR BAND in the scat@ of Minnesota and is In compliance with Minnesota Statutes 3268.197, and has filed a $25,000 mechanical bond to -perform gas, heating, ventilation. cooling, air conditioning, fuel burning, or refrigeration work in all areas or the state during the registration period: prdyided the work perforated complies with the State Mechankal Code and the ccrsificate holder maintains compllance with the required bond and workers' compensation laws. License: MECHANICAL•CONTRACTOR BOND -9 1,48R Major Mechanical LLC jFN Ypt11dda j li •25 760I Northland Dr N - �aIt 28 Ste 1117 " Brooklyn Park, MN 55428 1 DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/15/2025 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). COHTAC7 PRODUCER NAMe: Elisabeth Gass Holmes Murphy & Associates PHONtc FAX 2727 Grand Prairie Parkway E�1oJL 612-349-2415 FAX No - Waukee IA 50263 ADORES • egass@holmeamurphy.com INSURED Major Mechanical LLC 7601 Northland Dr. N Suite #110 Brooklyn Park MN 55428 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Western National Assurance Company 24465 MAJMECPC INSURER B : TBG/Midwest Employers Cas Co. 23612 F: rn�i�onr_�c PCDTICIr-'ATC AIIIkARIP-D- 7A717FR RFVISION NIIMPtFR7 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. 1NSR ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER D MMIQDfYYYY A X COMMERCIALGENERALLIABILITY CPP132714104 1/1/2026 1/1/2027 EACH OCCURRENCE $1.000,000 CLAIMS -MADE FKOCCUR PREMISES EaENTE occurrence $ 500,000 X MED EXP (Any one person) $ 5,000 Contr Liab Per X Policy Form XCU PERSONAL & ADV INJURY $ 1,000,000 QENLAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 ID PRO - POLICY [fl LOC $ OTHER, A AUTOMOBILE LIABILITY CPP132504905 1/1/2026 1/1/2027 COMBINEDSINGLELIMTT Ea)accident g1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Psr acpdeni $ Hired Auto Ph s Dm $ $50,000 A X UMBRELLALIAB X OCCUR UMB105461903 1/1/2026 1/1/2027 EACH OCCURRENCE $ 10.000,000 AGGREGATE $ 10,000.000 EXCESS LIAB CLAIMS -MADE DIED I X I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE 150001595/EWC010108 j 1/1/2026 1/1/2027 X I STA UTE 1 11 ER E.L. EACH ACCIDENT $ 1,000,1100 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) NIA' EL DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below A Leased/Rented Equipment Actual Cash Value CPP132714303 1/1/2026 1/1/2027 Limit: Deductible: $250,000 $500 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) All Work Performed CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights 14168 Oak Park Blvd N Oak Park Heights MN 55082 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT.KPR iZED R EPR E S E N TATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD