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HomeMy WebLinkAboutArchitect Mechanical 26-33 I 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: 4 R.6/4I TI ? A/ItK/-INIG/-4L rvc- Address: 2 q/7 4N7-F(o vy Ly - ,4A'7w'0 dy 3-5 y,'g Telephone: ( 0)-) 4436 -da O Fax: ( h')) E-mail STCrJe r� Alt cffNtG--chi 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 &NC -$50 Building Moving -$50 **Attach copy of MN Mechanical Bond Concrete and Masonry- $50 Outside Sewer&Water-$50 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: r -Z( Worker's Comp. Insurance Expiration: Co - ) -2 Mechanical Surety Bond ID: 00 Z 1 7_ Mechanical Surety Bond Expiration: q-I(a- LEAD ID & Expiration: Date License Issued: 2-6J Up No. 2l41 - J 3 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: /J(Complete only if applicable) Business Name: Business Address: a9/7 % rrYa Z / _S 7^ ANTlfO1/y A/1/7 Sy/g City State Zip Code Minnesota Tax Identification No.: 3 7(Wak3 Federal Tax Identification No.: `// /r063?Z If a Minnesota Tax Identification number is not required, please explain: Date: /Q /67 Signature: -- ` Title: fi(85./our --r2 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): u11O J J,JW,O?tiCE o��.�yyof�,� �2"'"f/ 6- Policy Number 6h`Ys�.31- a6 Dates of Coverage: 67i/a5 -- 67//a o.z 6 - 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 th- •- of y kno edge, the information provided is true and correct. Date: l-1/ 6/2 Signature ,► .. � � icy �� Prin -d Name of Signature PgeS_/Dwrvcc� Title/Position of Person Signing s 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. /a//`�s By: Date orporate Office or Individual Proprietorship Owner Subscribed and sworn to before me this 11-41- day of 0,_c<1,-,oei 4-r3 , Notary Public. loh✓ County. My commission expires: -3(-�`1 oFT e'T�J TATE GERAETS n4 Notary Public Minnesota :r My Commission Expires Jan.31,2029 Updated:01-01-2018 Minnesota Department of Labor and Industry • Licensing and Certification Services Construction Codes and Licensing Division Phone: 651.284-5034 443 Lafayette Road N Email: dti.license@state.mn•us Saint Paul,MN 55155 Website: www.dti.mn-gov NOTICES Architect Mechanical Inc NOT TRANSFERABLE pp. . 2917 Anthony Ln IF CHAUNGEBUSINESS STRUCTURE, 4 Minneapolis MN 55418-3238 YOUO MUST OBTANAR LICENSE FORNEWENTITY WHEN YOU RENEW OR REPLACE INSURANCE POLICY, PLEASE SUBMIT NEW CERTIFICATE OF INSURANCE NOTIFY US OF THESE CHANGES TO YOUR BUSINESS. Failure to do so may result in fines. 15-day notice requirement—Forms available at dli.mn.gov- • Change in business'physical address,mailing address,phone number or email address. • Change in control.owners,officers,directors,members or partners, • Change in business'legal name and/or assumed name. • Loss of or change in • Change in genera!liability insurance or workers'compensation insurance coverage YOUR CERTIFICATE IS BELOW THE PERFORATION, SHOW CERTIFICATE WHEN OBTAINING PERMITS. ni LLABORTMEN AND�DFUSTRY i MECHANICAL CONTRACTOR BOND Cons:rur,,nn CoCes and L,[enung Owrsron litenseng and CCnSica Udn Servrcpi at3Lafayette Road N St.Paul,MN$5155 Webts4 :vww.d8,mn.gov Emaii,dRiicer.ce stait.mn us Phone 653.284.503; This is to certify that the certificate holder is registered as a 41ECIl\NtCAt.CONTRACTOR BOND in the state of Minnesota and is in compliance with Minnesota Statutes 326/1.197.and has filed a S25,000 mechanical bond to perform gas,heating,ventilation.cooling.air conditioning,fuel burning,or refrigeration work in all areas of the state during the registration period:provided the work performed complies with the State Mechanical Code and the certificate holder maintains compliance with the required bond and workers compensation laws, License: MECHANICAI.CONTRACTOR BOND Number: MB00342$ Architect Mechanical Inc Effective date: 8/6/1024 2917 Anthony Ln Expiration date: 9t16/2026 Minneapolis MN 55418.3238 --- i ACo® CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYTY) 12/7/2025 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(iesj 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 ONE CT Bridget Whipps CISR • Brown&Brown Insurance Services.Inc. (PAHiONE Bet): (507)344-4501 FAX No): (866)800-6596 1120 South Avenue E-MAIL Bridget.Whipps@bbrown.com • ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC B North Mankato MN 56003 INSURER A: Union Insurance Company of Providence 21423 INSURED INSURER a: Employers Mutual Casualty Company 21415 Architect Mechanical Inc INSURER C: 2917 Anthony Ln INSURER D: INSURER•E; St.Anthony MN 55418 INSURER F: • COVERAGES CERTIFICATE NUMBER: 25/26 Term 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 LTR TYPE OF INSURANCE INNSSD SUBFF WVD POLICY NUMBER ' POLICY EFF POLICY EXP MI LIMITS(MMIDOIYYYY) (MDD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE X1 OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A 6D45431-26 06/01/2025 06/01/2026 PERSONAL&ADV INJURY $ 1,000,000 GEML AGGREGATE"1 JECATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I T [1 LOC 2,000,000 PRODUCTS-COMPIOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) 5 B OWNED SCHEDULED 6E45431-26 06/01/2025 06/01/2026 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) 8 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B X EXCESS LIAB CLAIMS-MADE 6J45431-26 06/01/2025 06/01/2026 AGGREGATE $ 5,000,000 DED XI RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR)PARTNER/EXECUTNE l� E.L.EACH ACCIDENT $ 1,000,000 • ` A OFFICER/MEMBEREXCLUDED? i l NIA 6H45431-26 06/01/2025 06/01/2026 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Byes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 B Leased/Rented Equipment 6C45431-26 '06/01/2025 06/01/2026 Limit $100,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) , CERTIFICATE HOLDER CANCELLATION • 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 Heights Blvd N AUTHORIZED REPRESENTATIVE� l Oak Park Heights MN 55082 i� c:r 4 �_ k ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD `