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HomeMy WebLinkAboutWright Tree Service Inc. 7 CONTRACTOR'S LICENSE APPLICATION i City of Oak Park Heights f 14168 Oak Park Blvd. N. P.O. Box 2007 Oak Park Heights, MN 55082 • TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439 -4439 - FAX: (651) 439 -0574 Email: jhultman @cityofoakparkheights.com Business Name: � ti Address: 9 (lra vfL 01/4\ (-2,Y. Oec, `no tvss (tk 50 Lie(, Telephone: (ci iJ) 90 ( Fax: (S6) M q —5); 7 E -mail *2% :it r, ► ,' s F 'WA t'e4fi 'Otla P wi t`I -tl; k.Cl ' 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 - $30 Heating, Ventilation & NC - $30 Building Moving -$30 "Attach copy ofMNMechanical Bond Concrete and Masonry - $30 Outside Sewer & Water -$30 Excavating /Grading - $30 Siding - $30 Pool Installation - $30 Signs & Billboa ds - $30 Irrigation System Installation - $30 jC Other: $30 tree t r t - 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: 1() 1 - Worker's Comp. Insurance Expiration: 10 - 1 t 3 Mechanical Surety Bond ID :OR Mechanical Surety Bond Expiration: j Date License Issued: l.. -31 - 2 No. ZOO) - OO Od `j 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: (,(1 I g f 1_t S (‘'(Cfc, i (17(c.._ Business Address: 7 C" j lrtd .AV cft Dew tr1e 9 to 56 JAW City State Zip Code Minnesota Tax Identification No.: IS 1(Ai ((- Federal Tax Identification No.: i4' ' s'6 d d If a Minnesota Tax Identification number is not required, please explain: Date: ( (1 ' ( l Signature: . �144 2 �' 1 In Title: Cam: �.O,a k 11\-th 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): eu i.Ch �rw rt coAL (44 Policy Number WC 5Q bZ 306 Dates of Coverage: (b ( (1 P. (01 ( 10 - 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 information provided is true and correct. r� / 11L (1 t' � Date: i, — (5 t Z_ Signature O( r et 16 I1 Printed Name of Signa ure Title /Position of Person Signing INDEMNIFICATION AGREEMENT To: City of Oak Park Heights 14168 Oak Park Boulevard, N. P.O. Box 2007 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. (9\ PI By: W.& l ----- Date Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to before me this ` day of De-i...- , NC (.4-. . -(11(4 ilk y , Notary Public. 6 4 County. My commis Iu At. rc * ELLIr PETTWOHN * Commission Number 164396 pws My Commission Expires MARCH 20, 2013 S:Shared /Forms & Publications /Contractor's License Application Updated: 01 -29 -2008 Ac oR° ' CERTIFICATE OF LIABILITY INSURANCE 09/28M/DD/YYYY) �� 09/28/2012 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 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 1- 612 - 333 -3323 CONTACT Deanna Brown NAME: Hays Companies PHONE 612 - 333 -3323 FAX 612 - 373 -7270 /A/C. No. Ext1: (A/C, No): 80 South 8th Street ADDDRE ADRE SS: Suite 700 PRODUCER Minneapolis, NN 55402 CUSTOMER ID N: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: ZURICH AMER INS CO 16535 Wright Tree Service, Inc. INSURERB: STARR IND & LIAB CO 38318 I PO Box 1718 INSURERC: AMERICAN ZURICH INS CO 40142 Des Moines, IA 50306 INSURERD: INSURER E : ' INSURER F : COVERAGES CERTIFICATE NUMBER: 29365834 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE B EEN 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 ADM SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER IMM/DD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL UABIUTY GL 0591264900 10/01/12 10/01/13 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 500,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 15,000 X BI /PD Ded. $350,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 7 POLICY PRO X .IFCT LOC $ A AUTOMOBILEUABILITY BAP 591264800 10 /01 /12 10/01/13 COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON -OWNED AUTOS $ X BI /PD Ded. $350,000 $ B X UMBRELLA LIAR X OCCUR SISCCCL01930812 10 /01 /12 10/01/13 EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE $ 5,000,000 DEDUCTIBLE $ RETENTION $ $ C AND EMPLOYERS' LIABILITY Y/N WC591265000 10 /01 /1 10/01/13 X TORY IMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,00 A Workers Compensation - Retro WC591265300 10 /01 /12 10/01/13 EmployersLiability lmm /lmm /lmm EL Disease -Ea EE 1,000,000 EL Disease Pol Lmt 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) City of Oak Park Heights is an Additional Insured under the General Liability policy as required by contract. CERTIFICATE HOLDER CANCELLATION City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd Box 2007 AUTHORIZED REPRESENTATIVE r Oak Park Heights, MN 55082 7 USA ��VVLL /I 4------- ' eric j © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 29365834 ' ® DATE(MMIDDIYYYY) AW Ro CERTIFICATE OF LIABILITY INSURANCE 09/27/2013 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 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 1-612-333-3323- -" CONTACT Sara Mc Wethy Y Hays Companies PHONE FAX (A/C,No.Ext): 612-333-3323 (AIC,No): 612-373-7270 80 South 8th Street E-MAIL smcweth ha scorn aniea.com ADDRESS: Y� Y P Suite 700 Minneapolis, MN 55402 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: ZURICH AMER INS CO 16535 INSURED INSURERS: AMERICAN GUAR & LIAB INS 26247 Wright Tree Service, Inc. INSURER C AMERICAN ZURICH INS CO 40142 5930 Grand Avenue INSURERD: West Des Moines, IA 50265 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 36036334 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 SUER POLICY EFF POLICY EXP LIMITS LTR INSR INVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) A GENERAL LIABILITY GLO591264901 10/01/13 10/01/14 EACH OCCURRENCE $5,000,000 X DAMAGE TO RENTED 500,000 COMMERCIAL GENERAL LIABILITY ,PREMISES(Ea occurrence) $__ _ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 15,000 X BI/PD Ded. $350,000 PERSONAL BADVINJURY $5,000,000 X See Agg Below GENERAL AGGREGATE $ 10,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 10,000,000 POLICY X JECT LOC $ A AUTOMOBILE LIABILITY BAP 591264801 10/01/13 10/01/14 COMBINED SINGLE LIMIT 5,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) X BI/PD Ded. $ B UMBRELLA LIAB X OCCUR SXS932696700 10/01/13 10/01/14 EACH OCCURRENCE $ 15,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 15,000,000 DED RETENTION$ $ C WORKERS COMPENSATION WC591265001 (AOS) 10/01/13 10/01/14 X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y/N A ANY PROPRIETOR/PARTNER/EXECUTIVE WC591265301 (WI) 10/01/13 10/01/14 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Oak Park Heights is an Additional Insured under the General Liability policy as required by contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oak Park Heights THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14168 Oak Park Blvd Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ddebuhr 36036334 DATE SUPPLEMENT TO CERTIFICATE OF INSURANCE NAME OF INSURED: (General Liability: Per Project Agg Limit is $5,000,000, and applies when required by written contract, subject to Overall General Agg Limit of $10,000,000 SUPP(10/00)