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HomeMy WebLinkAboutS & S Tree & Landscaping Specialists _ . CONTRACTOR'S LICENSE APPLICATION City of Oak Park Heights 14168 Oak Park Blvd. N. 1 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 s • 1 '1/4 Business Name: — - r - 6 eft %AG 11 so: it _I 114' 1 itS Address: •AD sira • tg OrAWatiahria Telephony Fax: 111:111M. E-mail \ COrn LICENSE REQUIREMENTS • Fee based on tracle. State license is required for residential general contracting, roofing, plumbing and fire " ,C C trabVis,re MN Ate Surktadnd. , '• 'ColtficateofIniiiearkde $1,05,000 perMilson, Publiniebility; $250,000 per accident, Bodily Iniury; and $100,000 Property Damage„CIF QFpAISPirlitiGHTS IUST BE NAMED AS AN ADDITIONAL _ISLIVED t . L ' . • 4liedme74to hictITY OP cbAKRARK HEIGHTS .trarmlees for clairqs:qt damage liability that may come against thd license/pernt halder. ! ' • • 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 pvriod: Janua0,1 to December 31.of each year. Cancellation will occur upon failure to provided , I 7 coninued Ofoof of insuraoceko■lerage. LICENSE CLASSIFIdATIONS: ' Gkeral Contractor - $50 1. • 48" . , • , .• • , BlaCktopping - $30 Ventilation &No - $30 Building Moving -$30 r ***Ittachopy of MN Mechanical Bond Concrete and Masonry - $30 r ;O:utOkSewer& Water - $30 Excavating/Grading 1 $3 1 4 f) Sitlingr- $30 Pool Installation - $30 ) Signs & Sitoards - $30 Irrigation System Indallation - $30 Other: $30 COMPLETION OF THE WORKERS COMPENSATION INSURANCE ANDTAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. THESE FORMS ARE ATTACHED AND MADE PART OF THIS APPLICATION. Office Use Only: Liability Insurance Expiration: WWI q - 30 - 1-5 Worker's Comp. Insurance Expiration: /-1-1"/ Mechanical Surety Bond ID : 0 P Mechanical Surety Bond xpir tion: Date License Issued: I c 't 12 No. ,2 01,3 • LICENSE APPLICANT: Pursuant to Minnesota Statute 270.072 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Govemment Data Practices Act and the. Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest; 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the Department of Revenue may ,Sup this Or-illation to the Internal R venue Servic . p �.. . .,+` a t" .wnfo f i 1 � r � . 3. Faitdre to #upply tffis n ;nay ardi$e,,�Alay- the in flra&ticenting issuaance or renewal application. f - r 4. ' , , jf. _ r �. •..'_1 � . .r Please provided ollIwing tnfo_Tation nd {atum Aibbg*tM Ypur ` f is 'jo ie agency issuing the license. Do pot..rgtiirnxo the De artmenf.o evenue;' i ' -i 'f ' 'i ' • •, • Licensing Authority: City of Oak Park Heights License Period: Annual: January 1 through December 31 Personal Information: (Complete only if applicable) • Applicant's Name: _ t 0 -.4i ∎ 11 * « 1 `I IPAS • Applicant's Address: �.• la%%. tir 11.1 City State ip Code Social Security No.: --- Business Information: (Complete only if applicable) Business Name: � !� t A. • Business Address: 1, r( _ r . .� t et City tate ip Minnesota Tax Identification No.: op a . _. Federal Tax Identification No.: etg • If a Minnesota Tax Identification number is not required; please explain: Date: Signature: Title: 1 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 1. rance Agent): nTri f • Policy Number L U , •• ?704 � Dates of Coverage: 11 ` b / c ' / `' - OR - 1 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' Comp sa ' n coverage 2' d hereby certify by my signature below that to the best of my knowledge, the fo ation pr'' i' is true and correct. Date: ___La244_?..._ Signature aft e Printed ame of Signa u 1 Title /Position o 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 signed by ail Offleor` rlf•f Uratfer 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•{tr the Contractor's agents or employees engaged in the performance of this Contract/Permit, and y w rdem rofy tJae;i for the atria ditk cfair, liens, expenses and claims for hens of work, tool, machinery; matenals or tnsurancq premiums . pnd- forlhe amour( 'of all, loss by'reasort of the failure of the Cori(ractor to fully perform itsiobliga,116 Zontjactpeirpii,irtslud ng.liut vo "limited to attorney fees and costs incurred relative to such claims' anc ,'tgs»es. • By: Date Corporate Officer or Individual Proprietorship Owner I I Subscribed and sworn to before me this day of , Notary Public. County. My commissi4grexr res:. , ! +• • T S:Shared/Forms & Publications/Contractor's License Application Updated: 01 -29 -2008 � � DATE CERTIFICATE OF LIABILITY INSURANCE `./.- 01/23/2013 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 CONTACT NAME: SHERMAN INSURANCE AGENCY, INC PHONE .41 651- 451 -1758 _FA 651- 955 -3923 120 BRIDGEPOINT WAY, SUITE C E - MAIL Laural @shermanins.com SOUTH ST PAUL, MN 55075 -2498 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Travelers INSURED 651 - 451 - 8907 INSURER B: American Interstate Insurance Company S & S Tree & Horticultural Specialist Inc. INSURERC: 405 Hardman Ave. S. INSURER D : South Saint Paul, MN 55075 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM /DDIYYYY) LIMITS j GENERAL LIABILITY EACH OCCURRENCE $ 1, 000, 000 A X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY ZPP 11P51356 - 12 - 47 09/30/2012 09/30/2013 PREMISES (Ea occurrence) $ 100, 000 1 CLAIMS -MADE X I OCCUR MED EXP (Any one person) $ 5, 000 X professional Liab. $1,000,000 PERSONAL &ADV INJURY $ 1,000,000 X Blkt Contractual Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 — 1 POLICY I " 1 jF n LOC Professional Liab $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 1 , 000, 000 _ A X ANY AUTO BA - 0112P622 12 – GRP 09/30/2012 09/30/2013 BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS X AUTOS ((Peraccident) PROPERTY DAMAGE $ QmM Pclvat. Pa... Omed A.th. O/T P... $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE ZUP 13T45117 - – 09/30/2012 09/30/2013 AGGREGATE $ 2,000,000 DED 1 RETENTION $ $ WORKERS COMPENSATION x I W C Y T LIMITS] I T AND EMPLOYERS' LIABILITY ER B ANY PROPRIETOR/PARTNER /EXECUTIVE YIN E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? Y I NIA AVWCMN2170632013 01/01/2013 01/01/2014 (Mandatary in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 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. 19168 Oak Park Blvd N PO Box 2007 AUTHORIZEDREPRESENTATiVE Oak Park Heights, MN 56357 2Q 1,.02. © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD , ® DATE(MM/DD/YYYY) A�D CERTIFICATE OF LIABILITY INSURANCE 09/30/2013 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). CONT PRODUCER NAMEACT Sherman Ins. Agcy., Inc. PHONE 1758 FAX 651-455-3923 SHERMAN INSURANCE AGENCY, INC 651-451- C.No.Extl: (NC,No): 120 BRIDGEPOINT WAY, SUITE C MAIL ADDRESS: ron @shermanins.com SOUTH ST PAUL, MN 55075-2498 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: AmTrust North America INSURED 651-451-8907- INSURERB: American Interstate Insurance Company S & S Tree & Horticultural Specialist Inc. INSURERC: 405 Hardman Ave. S. INSURERD: South Saint Paul, MN 55075 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. ADDL SUBR POLICY EFF POLICY EXP INSR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY WPP1117941 09/30/2013 09/30/2014 PR PREEMIMI ESORENTED SES(Ea occurrence) $ 100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X professional Liab. $1,000,000 PERSONAL&ADVINJURY $ 1,000,000 X Blkt Contractual Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY jECT LOC Professional Liab $ 1,000,000 AUTOMOBILE LIABILITY (Ea accident SINGLE LIMIT $ 1,000,000 A X ANY AUTO SPP1105139 05/16/2013 05/16/2014 BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESSLIAB CLAIMS-MADE WPP1117941 09/30/2013 09/30/2014 AGGREGATE $ 2,000,000 DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A AVWCMN2170632013 01/01/2013 01/01/2014 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 Blvd N PO Box 2007 AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 56357 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD