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HomeMy WebLinkAboutAsplundh Tree Expert Co 'Aar. 12. 2013 1:22PM No. 2920 P. 2 4 CONTRACTOR'S LICENSE APPLICATION City of Oak Park Heights 14168 Oak Park Blvd. N. P.O. Box 2007 Oak Park Heights, MN 55082 TELEPHONE: DIRECT: (651) 351.1661 GENERAL: (651) 439- 4439 - F : (651) 439 -0574 Email: jhullman ©cityofoakparkheights.com Business Name: ASPLUNDH TREE EXPERT CO. 4501 iu3ku LI Nvt, STt; ISU Address: Telephone: (7 , 3 ? Fax: W.5 r3y0� E -mail, LICENSE REQUIREMENTS • Fee based on trade. Stale license is required for residential general contracting, roofing, plumbing and fire protection. Mechanical Contractors require MN Slate 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 (allure to provided • continued proof of insurance coverage.- ,;; : i :, f 1 i4,) ill I I LICENSE CLASSIFICATIONS:, ,< i I i p"! C9mfmrciial general Contractor- $50 Blacktopping - $30 Healing, Ventilation & NC - $30 Building Moving -$30 - Attach copy of MN Mechanical Bond Concrete and Masonry - $30 Outside Sewer & Water -$30 Excavaling /Grading - $30 Siding • $30 Pool Installation - $30 Signs & Billboards - $30 Irrigation System Installation - $30 - i� Olher. $30 r2rf R PLAN /7n. 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 PI THIS APPLICATION. Office Use Only: Liability Insurance Expiration: 8 `I -14) Worker's Comp. Insurance Expiration: A -I -1/3/ Mechanical Surety Bond ID :- e Mechanical Surety Bond Expiration: ti Date License Issued: xi -) s 'I No. ca01 Apr. 12. 2C13 1:23PM, No, 2920 P. 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,[g4y Jsgpardizggrile(ay,;ttgogesping'gf.your licensing issuance or renewal application. t:t "'N l t1e:' 110.11 ,' 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 Slate Zip Code Social Security No.: Business Information: (Complete only if applicable) Business Name: A TREE EXPERT CO. 4501 103RD CT NE, STE 180 Business Address: City Stale Zip Coda • Minnesota Tax Identification No.: (05 7%03 Federal Tax Identification No.: " i! � 0 If a Minnesota Tax Identification number is not required, please explain: Date: 7' 13 Signature %f 4 � Title: Ellie/ �/e /i Apr. 12. 2013 1:23PM No. 2920 P. 4 r y . 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 unlit 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): 1 ! / I )7i `'tia f Policy Number / 943i) 2 '5 2,,Q _ Dates of Coverage: 8 c./ ru Z- 1 - 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 ,e-- . , ! AT02?1�S,k1 D O!�.Ua Ynt'i ).1 :. , :1; ;, WI tiavd•read andkmtf rtla ay, ig, s and obligations with regards to business licenses, permits and "-'4/irkieettffiRgitiortl and hereby certify by my signature below that to the best of my know -dge, the information provided is true and correct. $/? I,I/kJ� /fAtiot / Date: — /`3 Siena ure . t e: /e),) Prin ed Name of Signature �� j l /YI /7) Title /Position of Person Signing Apr. 12. 2013 1: 23PM. No. 2920 P. 5 r �pry 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 Contractors agents or employees engaged in the performance of this ContractlPermlt, and will Indemnify the City for the amount of all claims, liens, expenses and claims for )lens 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 ContracVPermil, including but nol limited to attorney fees and costs Incurred relative to such claims and losses. • k — /3 By: i• /A. • Date Corporate 0 ►- or Individual Proprietorship Owner Subscribed and sworn to efore me z this 1 � day. of _ /) PO/5 ' �,,, HEATHER KOONCE 4, ,e 1 I' //I NOTARY PUBLIC • MINNESOTA ��/ Nolary Public. •y , tidCanmissionEgiresJan.51,2o>le ya -ek(/ - - County. My Tres; / ex commission Y P S:SharediForms & Publicalfons!Contracto?s License Application Updated: 01 -29 -2009 Apr. 12. 2013 1:23PM No. 2920 P. 6 DATE (MM/DD!YY) ' CERTIFICATE OF LIABILITY INSURANCE 4/12/2013 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: II the certificate holder Is an ADDITIONAL INSURED, the policy(lee) must be endorsed. H SUBROGATION IS WAIVED, subject to the !arms and condllions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the cerllllcate holder In lieu of such endorsement(s). P RODUCER CONTACT NAME Aon Risk Services Central, Inc. (Primary Casualty Broker) PHONE FAX PNIadelpNa PA OtlIca 215 I 215 - 255 - 1886 One Liberty Place, Suite 1000 (A/C No. Exi): (AlC, Na): Philadelphia, PA 19103 E-MAIL ADDRESS: Marsh. Inc. (Umbrella Excess Broker) PRODUCER Two Logan Square. 22nd Boor CUSTOMER IO ?: Philadelphia PA, 19103 INSURER(S) AFFORDING COVERAGE NAIC it INSURED INSURER A: LIBERTY MUTUAL FIRE INSURANCE COMPANY Asplundh Tree Expert Co, INSURER B: I IRFRTY INSURANCF CORPORATION 708 Blair Mill Road INSURER 0: Willow Grove. PA 190901784 INSURER 0: i INSURER E: Region Code: 065 INSURER F: COVERAGES CERTIFICATE NUMBER: 2144969710 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. LIMITS SHOWN ARE AS F OM TYPE OF *6URANGE ADM CUM POLICY RUBBER POUCY EFFECTIVE POLICY EXPIMTION MYRe LTA ma W 'D *ATE DattleYYTYT) DATE (YMDD YYTY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A � TB2- 631 - 004928 -952 8/112012 8/1/2013 LYl=WE FOAL GENERAL WORRY DAMAGE TORENTE0 $ ❑cuums MADE © ate PREMISES (Es occurrence) ❑/ Broad Form CenVedual ❑ ❑ MED EXP (Any one person) $ ❑ PERSONAL aAOVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 i 1NL AGGREGATE OMIT APPLIES PER; PRODUCTS COMP/OP AGO 1 1,000,000 ❑P«,GY © maser Loo A Wpm AU AUTOMOBILE LIABILITY COWING() V AS2.631- 004328.052 8/1/2012 8/1/2019 $ 1,000,000 n... ,� (Es act u,OWNEOAUTOS BODILY INJURY $ ❑scHE Iuonuros ❑ ❑ AS1- S31.004928.182(VI) BODILY B BODILY NJURY DJREO AUTOS $ (Pei sodden!) DoNOwNEOatrTOS PROPERTY DAMAGE $ ❑ (Per accident) 0UueRELLALIAR _ OCCUR EACH OCCURRENCE $ EXGesS CIJJUE•uADE ❑ CI R AGGREGATE _ $ DEOUcr,&Le $ RETENTION t $ WORKERS' COMPENSATION ANO WA7 -6SD- 004328. 012 8/1/2012 8/1/2013 b(jWCSTATU- Uo1>♦ER _ _,. • B EFAPLOYFR9' LIABILITY TORY I. • •._�•� ANY PAOPR1EYoRPAATNEFVECECUTWWE (AOS) E.L. EACH ACCIDENT $ 1000000 IMvwb+r RA OFFICEAELM tot BFA EXCiUDE01 I N I WA ❑ WC7. 631 - 004328 -022 (M) E.L,DISEASE— EAEMPLOYEE $ 1,000,000 DESCRIPTION OF O PERAUONS Debra WA7- 63D•004328- 572(MN E.L. DISEASE — POLICY LIMIT $ 1,000,000 ❑ ❑ DBSCRIPTIGN OF OPERATIONSI LOCATIONS / VEHICLES (Allach ACOPO 101, AdolIIonal Remarks Schedute, II more space le reQUlred) The City of Oak Park Heights IS listed as additional Insured as required by written agreement but only according 10 policy Lerma, caldl(Ionss and exctuslons for liability arising from operations performed by or on behalf of the named insured. — icljoa,1(I1m:. ir,o)II11.1;(_ r' /'.%/ - I•I•I; ,: . .`t'�— - : -7 2.: �_ City of Oak Park Heights : SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE W ILL BE DELA/ERE° IN ACCORDANCE WITH THE POLICY PROVISIONS. 14188 Oak Park Blvd. N. ; P.O. Bolt 2007 + ■ AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 I Ao Risk Services Central, Inc. L•1 =1r) 1. ;•!I:01.1II _ - - _ q: 1, 1,1 . tjl I11At:011T^r1_. The ACORD name end logo are registered marks of ACORD ..� DATE (MM/DD/YY) c�ccf CERTIFICATE OF LIABILITY INSURANCE 7/1/2013 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 Aon Risk Services Central, Inc. (Primary Casualty Broker) PHONE Philadelphia PA Office 215- 255 -2000 I FAX 215 255 -1886 (NC No. Ext): One Liberty Place, Suite 1000 (A/C, No): Philadelphia, PA 19103 E-MAIL ADDRESS: Marsh, Inc. (Umbrella Excess Broker) PRODUCER Two Logan Square, 22nd floor CUSTOMER ID #: Philadelphia PA, 19103 INSURER(S) AFFORDING COVERAGE NAIC # INSURED �`r\n 4 INSURER A: LIBERTY MUTUAL FIRE INSURANCE COMPANY_ Asplundh Tree Expert Co. 2U U INSURER B: LIBERTY INSURANCE CORPORATION 708 Blair Mill Road INSURER C: Willow Grove, PA 190901784 INSURER D: INSURER E: Region Code: 065 INSURER F: COVERAGES CERTIFICATE NUMBER: 2144974913 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. LIMITS SHOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR WVD DATE (MM/DD/YYYY) DATE (MMIDDIYYYY) A GENERAL LIABILITY TB2- 631 - 004328 -953 8/1/2013 8/1/2014 EACH OCCURRENCE $ 1,000,000 n COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ❑CLAIMS MADE OCCUR PREMISES (Ea occurrence) Q Broad Form Contractual ❑ ❑ MED EXP (Any one person) $ ❑ PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS — COMP /OP AGG $ 1,000,000 ❑ POLICY 0 PROJECT LOC A UTOMOBILE LIABILITY C OMBINED SINGLE LIMIT A AS2 631 - 004328 -053 $/1/2013 8/1/2014 $ 1,000,000 ©ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑SCHEDULED AUTOS ❑ ❑ AS6- 631 - 004328- 183(VI) (Per person) BODILY INJURY ❑ HIRED AUTOS (Per accident) NON OWNED AUTOS PROPERTY DAMAGE ❑ (Per accident) H UMBRELLA LIAB El OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE ❑ ❑ AGGREGATE $ ❑ DEDUCTIBLE $ n RETENTION S $ WORKERS' COMPENSATION AND WA7 -63D- 004328 -013 8/1/2013 8/1/2014 Q We STATU- ❑ OTHER . " <"�. ; e a �� B EMPLOYERS' LIABILITY TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE (AOS) E.L OFFICER/MEMBER EXCLUDED? N/A . EACH ACCIDENT $ 1,000,000 (Mandatory in NH) WC7- 631 - 004328 -023 (WI) E.L. DISEASE — EA EMPLOYEE $ 1,000,000 DESCRIPTION des under WA7 - 63D- 004328 -573 MN 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) The City of Oak Park Heights is listed as additional insured as required by written agreement but only according to policy terms, conditions and exclusions for liability arising from operations performed by or on behalf of the named insured. CERTIFICATE HOLOi City of Oak Park Heights SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 14168 Oak Park Blvd. N. ' THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 2007 ` AUTHORIZED REPRESENTATIVE Oak Park Heights, MN 55082 - Aon Risk Services Central, Inc. ) � ..... ' w' 4 O } CO O , At rtgtttt ..,` ed 3` AL`+OD 219109 -y„ � ,�, . � � The ACORD name and logo are registered marks of ACORD Named Insured Certificate Holder Asplundh Tree Expert Co. City of Ocala 708 Blair Mill Road Finance Department Willow Grove, PA 19090 -1784 151 SE Osceola Avenue Ocala, FL 34471 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: 2144974597 COMMERICAL GENERAL LAIBLIITY COVERAGE FORM SECTION II - WHO IS AN INSURED is amended to include as an insured any person or organization for whom you have agreed in writing to provide liability insurance. But: The insurance provided by this amendment: 1. Applies only to "bodily injury" or "property damage: arising out of (a) "your work" or (b) premises or other property owned by or rented to you; 2. Applies only to coverage and minimum limits of insurance required by the written agreement, but in no event exceeds either the scope of coverage or the limits of insurance provided by this policy; and 3. Does not apply to any person or organization for whom you have procured separate liability insurance while such insurance is in effect, regardless of whether the scope of coverage or limits of insurance of this policy exceed those of such other insurance or whether such other insurance is valid and collectible. The following provisions also apply: 1. Where the applicable written agreement requires the insured to provide liability insurance on a primary, excess, contingent, or any other basis, this policy will apply solely on the basis required by such written agreement and Item 4. Other Insurance of SECTION IV of this policy will not apply. 2. Where the applicable written agreement does not specify on what basis the liability insurance will apply, the provisions of Item 4. Other Insurance of SECTION IV of this policy will govern. 3. This endorsement shall not apply to any person or organization for any "bodily injury" or "property damage" if any other additional insured endorsement on this policy applies to that person or organization with regard to the "bodily injury" or "property damage ". 4. If any other additional insured endorsement applies to any person or organization and you are obligated under a written agreement to provide liability insurance on a primary, excess, contingent, or any other basis for that additional insured, this policy will apply solely on the basis required by such written agreement and Item 4. Other Insurance of SECTION IV of this policy will not apply, regardless of whether the person or organization has available other valid and collectible insurance. If the application written agreement does not specify on what basis the liability insurance will apply, the provision of Item 4. Other Insurance of SECTION IV of this policy will govern. Policy Number: TB2 -631- 004328 -953