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HomeMy WebLinkAboutMike Smith Construction Services LLC 404 14_ P w ol-IA. CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 - 4439 CITY OF OAK PARK HEIGHTS 2012 Z t5 TREE WORKER'S LICENSE APPLICATION Date: 1 7' 2 2©rC.3 Firm or Business Name: / /tiP , 57/2,./1 11 1Sfra q 9 w S?P.', ces Type of tree work to be performed: - e-6Y10 ■ia-Q LICENSE REQUIREMENTS • Certificate of Insurance, minimum coverage, $1,000,000 combined single limit coverage, covering all operations of the applicant. THE CITY OF OAK PARK HEIGHTS MUST BE NAMED AS AN ADDITIONAL INSURED on this policy. • Agreement to hold THE 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. -.5-0G f6 • 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. Licenses held in nearby cities: (\ Has your company ever had a license revoked in any other city? (YES) TN If yes, where? /,_ ��''�� / LICENSE FEE: $30.00 , /?il� /2 75i S ✓r .3 /L c Name of Business or Company COMPLETION OF THE WORKERS / 372_ /9v1 COMPENSATION INSURANCE AND Business Street Address TAX I.D. FORMS IS REQUIRED BEFORE A LICENSE CAN BE ISSUED. d L .k. • 5Vd8Z- �N , THE FORMS ARE ATTACHED. City State Zip Code LICENSE EXPIRES THE END OF ( 0261 ) 303 - ` 3 P'f THE CALENDAR YEAR WITHIN Phong Number WHICH APPLIED FOR OR UPON Oh..L EXPIRATION OF LIABILITY Email Address INSURANCE OR WORKERS' COMP. COMPENSATION INSURANCE, WHICHEVER OCCURS FIRST. License No.TW: Date: 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: The City of Oak Park Heights License Renewal Date: Annually (January 1st through December 31 Personal Information: (Complete only if applicable) Applicant's Name: , ec -e-43, r - Applicant's Address: I 3 � L jo 4 -) J`�f. y City State Zip Code Social Security No.: Business Information: (Complete only if applicable) /)'� i y (20 „5/7„, fi %w Svc 's LL C Business Name: � f' S/�'J� Business Address: 1 8 2' t_4 )9 +J ,"f ZC), • .5 62_ City State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: If a Minnesota Tax Identification number is not required, please explain: (5' 7- - 20 %3 Signature Titre D Date CITY OF OAK PARK HEIGHTS 14168 OAK PARK BOULEVARD - Box 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 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 Section 176.181, subdivision 2. 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 placed within their company file. It shall be furnished, upon request, to the Department of Labor and Industry to check for compliance with Minnesota Statue, Section 176.182, subdivision 2. Law requires this information; licenses and permits to operate a business may not be issue 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 $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry to the Special Compensation Fund. 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 or Self- Insurance Permit Number: Dates of Coverage: OR I am not required to have Workers' Compensation Insurance because: (check one) I have no employees covered by law 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. �1 Aird;rt f Svc °4 LL.& Signature Business Name Date: 1 ^ 201 3 u. N, rc �� ��r� u siness Address Telephone Number: 30 3 -- `/3 7 CITY OFOAK PARK HEIGHTS 14168 OAK PARK BOULEVARD- BOX 2007 OAK PARK HEIGHTS, MINNESOTA 55082 (651) 439 -4439 INDEMNIFICATION AGREEMENT To: The City of Oak Park Heights 14168 Oak Park Boulevard 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. - 7- 2 -20/ 3 By: Date Corporate Officer or Individual Proprietorship Owner Subscribed and sworn to to before me 0 this day of c \ ))1 kied6/44t8' ili r -'�.. - Notary Public. - . County. My commission expires: S:Shared /Forms /Arborist /Tree Worker's License Application COMMERCIAL LINES POLICY - COMMON POLICY DECLARATIONS Ref#0122121 NAUTILUS INSURANCE COMPANY Transaction Type: Renewal Policy No. NN323899 Renewal of Policy # NN201057 Inspection Ordered: Rewrite of Policy # E] Yes ® No This insurance contract is with an insurer which has Cross Ref. Policy It not obtained a certificate of authority to transact a NIG Quote # regular insurance business in the state of Wisconsin, Named Insured and Mailing Address and is issued and delivered as a surplus line (No., Street, Town or City, County, State, Zip Code) coverage pursuant to s. 618.41 of the Wisconsin Mike Smith Construction Services, LLC. Statutes. Section 618.43(1), Wisconsin Statutes, requires payment by the policyholder of 3.0% tax on 1382 Haggerty St. gross premium. Houlton WI 54082 - Saint Croix County Agent and Mailing Address Agency No. 22030 - 00 (No., Street, Town or City, County, State, Zip Code) Risk Placement Services, Inc. - Minneapolis 7300 Metro Blvd, Suite 355 Minneapolis, MN 55439 NO FLAT CANCELLATION • Policy Period: From 02/12/2013 to 02/12/2014 at 12:01 A.M. Standard Time at your mailing address shown above. Business Description: Tree Trimming Tax State WI Form of Business: ❑ Individual ❑ Partnership ❑ Joint Venture ❑ Trust © Limited Liability Company (LLC) ❑ Organization, including a Corporation (but not including a Partnership, Joint Venture or LLC) IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE WILL PROVIDE YOU THE INSURANCE STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial General Liability $ 630.00 $ $ $ Tax - &- Fee Schedule TOTAL ADVANCE PREMIUM $ 630.00 Surplus Lines Tax $ 21.15 TOTAL TAXES & FEES $ 96.15 Policy Fee 75.00 TOTAL $ 726.15 Form(s) and Endorsement(s) made a part of this policy at time of issue: Refer to Schedule of Forms and Endorsements. A0022137: Sunrise Park Ins. Agency, Inc. �yft� White Bear 2063 Country Red E E551. �G' �"i/ White B Lake, MN 55110 Countersigned: Minneapolis, MN By 02/19/2013 PDALAVI Countersignature or Authorized Representative, whichever is applicable drsessin THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORMA PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of Insurance Services Office, Inc., with its permission. E001 (04 /09) ORIGINAL RPS Minneapolis (RPSSC) COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS POLICY NUMBER: NN323899 ❑ Extension of Declarations is attached. Effective Date: 02/12/2013 12 :01 A.M. Standard Time LIMITS OF INSURANCE ❑ If box is checked., refer to form S132Amendment of Limits of Insurance. General Aggregate Limit (Other Than Products /Completed Operations) $ 1,000,000 Products /Completed Operations Aggregate Limit $ 1,000,000 Personal and Advertising Injury Limit $ 500, 000 Any One Person Or Organization Each Occurrence Limit $ 500,000 Damage To Premises Rented To You Limit $ 100,000 Any One Premises Medical Expense Limit $ 5,000 Any One Person RETROACTIVE DATE (CG 00 02 ONLY) This insurance does not apply to "bodily injury", "property damage" or "personal and advertising injury" which occurs before the Retroactive Date, if any, shown here: NONE (Enter Date or "NONE" if no Retroactive Date applies) BUSINESS DESCRIPTION AND LOCATION OF PREMISES BUSINESS DESCRIPTION: Tree Trimming LOCATION OF ALL PREMISES YOU OWN, RENT, OR OCCUPY: ® Location address is same as mailing address. 1.1382 Haggerty St. Houlton WI 54082- 2. Additional locations (if any) will be shown on form S170,Commercial General Liability Coverage Part Declarations Extension. LOCATION OF JOB SITE (If Designated Projects are to be Scheduled): PREMIUM RATE ADVANCE CODE # - CLASSIFICATION 1 BASIS Prem /Ops Prod /Comp PREMIUM Ops 99777 _ Tree Pruning, Dusting, Spraying, Repairing, p 19,500 23. 625 604 MP Trimming or Fumigating INCLUDED INCLUDED 91342 - Carpentry NOC P 500 21.759 14 MP 18.964 12 MP 4. PREMIUM BASIS SYMBOLS - = Products /Completed Operations are subject to the General Aggregate Limit a = Area (per 1,000 sq. ft. of area) o = Total Operating Expenditures s = Gross Sales (per $1,000 of Gross Sales) c = Total Cost (per $1,000 of Total Cost) (per $1,000 Total Operating Expenditures) t = See Classification m= Admissions (per 1,000 Admissions) p = Payroll (per $1,000 of Payroll) u = Units (per unit) PREMIUM FOR THIS COVERAGE PART $ 630 MP FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the policy) Forms and Endorsements applying to this Coverage Part and made part of this policy at time of issue: Refer to Schedule of Forms and Endorsements THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD. Includes copyrighted material of Insurance Services Office, Inc. with its permission. S150 (07/09)