"Trades License Application Form" - City of Minneapolis, Minnesota

"Trades License Application Form" - City of Minneapolis, Minnesota Download Pdf
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Trades License Application Form is a legal document that was released by the Community Planning and Economic Development Department - City of Minneapolis, Minnesota - a government authority operating within Minnesota. The form may be used strictly within City of Minneapolis.

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City of Minneapolis
Licenses and Consumer Services
th
350 South 5
Street – Room 1
For Office Use Only
Minneapolis, MN 55415–1391
Expiration: December 1
Phone: 612-673-2080
License Code: L101
Fax: 612-673-3399 TTY: 612-673-2157
Rev Code: 311011
www.minneapolismn.gov/business-licensing
MCO:
278
License Application
Adm Issuance: Yes
Guidelines and Checklist
License Type: Plumber
DEFINITION: A Plumbing Contractor may provide or offer to provide the following: (1) Connections with the water pipes,
water mains, branch sewers, main sewers, drains or other service pipes of the city; (2) Repairs, additions or alterations of
any pipe, tap, stopcock, water closet or any other fixture connected with or designed to be connected with the water works
or sewer system with the city; (3) Install, alter or repair any atmospheric burner; (4) Install, alter or repair any power
burner that does not exceed one hundred thousand (100,000) btu's; (5) Install, alter or repair fuel gas piping, combustion
air piping, fuel gas venting or gas burner equipment; (6) Install, alter or repair any power burner equipment, provided said
contractor has in his employ a person holding a valid Master Gas Fitter Certificate of Competency issued by the City of
Minneapolis. At no time may a Plumber Contractor install, alter, or repair any environmental burner. Items (3), (4), (5) and
(6) shall not apply to a contractor licensed only as a Gas Fitter Contractor.
Application Checklist
Staff
th
Minneapolis Development
Review, 250 South 4
Street
Submit items below to:
Initials
Room 300 Public Service Center, Minneapolis, MN 55415 -
Free Parking
1. License Application (Form #1)
2. Certificate of Liability Insurance (Sample Form #2)
a. This must be furnished by your Insurance Agent with the mandatory changes.
b. You are required to have general liability which includes premises and operations insurance and products
and completed operations insurance with the following coverages:
$100,000 per occurrence and $300,000 aggregate for bodily injury
$100,000 per occurrence and $300,000 aggregate for property damage
3. A copy of the $25,000 bond filed with the State of Minnesota.
www.doli.state.mn.us
4. A copy of a current
City of Minneapolis Master Competency Card
for employee or owner.
5. __________
Fee
plus
new license surcharge
This Section To Be Completed by Minneapolis Development Review Coordinator
DC:__________________________________ Temporary Application Number:__________________
__________________
Plumbing Permit
Mechanical Permit
Building Permit
SAC
Sidewalk Inspection
PDR Review
SAC Determination Letter Required:
Yes
No
Date Sent to EH _________________________________________
PCAB # _______________________________________________
EH Staff Initials _________________________________________
EM Staff Initials ________________________________________
Date Sent to EM
Date Returned to MDR __________________________________
Additional Information
1. Your License Application
a. Incomplete applications will be returned.
b. All applications must be signed by the owner.
c. No license will be issued for a period longer than one year.
d. Licenses are not transferable.
e. Make a duplicate copy of this packet for your personal records before submitting.
f.
Minnesota Sales Tax ID Number
or 651-296-6181.
g. If you are applying for multiple licenses, applications may be combined. Talk to Licenses’ Staff at 300 Public Service Center.
2. Bond
a. Information must be on the attached a State of Minnesota Bond Form. This is a continuous bond and valid until cancelled.
b. The amount of the bond must be the same as the amount listed above.
c. The name of the licensee and the principal on the bond must be the same.
d. Bond must be signed and notarized by the principal and the agent/surety. There must be two witnesses for each signature.
e. Bond must include an acknowledgment of surety and the agent’s power of attorney.
3. Hours of Operation – 1 City Hall: Mondays – Thursdays: 8:00 am – 4:00 pm. Fridays: 10:00 am – 4:00 pm.
4. Information in Other Languages: Para asistencia 612-673-2700 - Rau kev pab 612-673-2800 - Hadii aad Caawimaad u baahantahay 612-673-3500.
This application must be stapled and all pages attached to avoid processing delays. Page 1 of 4 - October 2015
City of Minneapolis
Licenses and Consumer Services
th
350 South 5
Street – Room 1
For Office Use Only
Minneapolis, MN 55415–1391
Expiration: December 1
Phone: 612-673-2080
License Code: L101
Fax: 612-673-3399 TTY: 612-673-2157
Rev Code: 311011
www.minneapolismn.gov/business-licensing
MCO:
278
License Application
Adm Issuance: Yes
Guidelines and Checklist
License Type: Plumber
DEFINITION: A Plumbing Contractor may provide or offer to provide the following: (1) Connections with the water pipes,
water mains, branch sewers, main sewers, drains or other service pipes of the city; (2) Repairs, additions or alterations of
any pipe, tap, stopcock, water closet or any other fixture connected with or designed to be connected with the water works
or sewer system with the city; (3) Install, alter or repair any atmospheric burner; (4) Install, alter or repair any power
burner that does not exceed one hundred thousand (100,000) btu's; (5) Install, alter or repair fuel gas piping, combustion
air piping, fuel gas venting or gas burner equipment; (6) Install, alter or repair any power burner equipment, provided said
contractor has in his employ a person holding a valid Master Gas Fitter Certificate of Competency issued by the City of
Minneapolis. At no time may a Plumber Contractor install, alter, or repair any environmental burner. Items (3), (4), (5) and
(6) shall not apply to a contractor licensed only as a Gas Fitter Contractor.
Application Checklist
Staff
th
Minneapolis Development
Review, 250 South 4
Street
Submit items below to:
Initials
Room 300 Public Service Center, Minneapolis, MN 55415 -
Free Parking
1. License Application (Form #1)
2. Certificate of Liability Insurance (Sample Form #2)
a. This must be furnished by your Insurance Agent with the mandatory changes.
b. You are required to have general liability which includes premises and operations insurance and products
and completed operations insurance with the following coverages:
$100,000 per occurrence and $300,000 aggregate for bodily injury
$100,000 per occurrence and $300,000 aggregate for property damage
3. A copy of the $25,000 bond filed with the State of Minnesota.
www.doli.state.mn.us
4. A copy of a current
City of Minneapolis Master Competency Card
for employee or owner.
5. __________
Fee
plus
new license surcharge
This Section To Be Completed by Minneapolis Development Review Coordinator
DC:__________________________________ Temporary Application Number:__________________
__________________
Plumbing Permit
Mechanical Permit
Building Permit
SAC
Sidewalk Inspection
PDR Review
SAC Determination Letter Required:
Yes
No
Date Sent to EH _________________________________________
PCAB # _______________________________________________
EH Staff Initials _________________________________________
EM Staff Initials ________________________________________
Date Sent to EM
Date Returned to MDR __________________________________
Additional Information
1. Your License Application
a. Incomplete applications will be returned.
b. All applications must be signed by the owner.
c. No license will be issued for a period longer than one year.
d. Licenses are not transferable.
e. Make a duplicate copy of this packet for your personal records before submitting.
f.
Minnesota Sales Tax ID Number
or 651-296-6181.
g. If you are applying for multiple licenses, applications may be combined. Talk to Licenses’ Staff at 300 Public Service Center.
2. Bond
a. Information must be on the attached a State of Minnesota Bond Form. This is a continuous bond and valid until cancelled.
b. The amount of the bond must be the same as the amount listed above.
c. The name of the licensee and the principal on the bond must be the same.
d. Bond must be signed and notarized by the principal and the agent/surety. There must be two witnesses for each signature.
e. Bond must include an acknowledgment of surety and the agent’s power of attorney.
3. Hours of Operation – 1 City Hall: Mondays – Thursdays: 8:00 am – 4:00 pm. Fridays: 10:00 am – 4:00 pm.
4. Information in Other Languages: Para asistencia 612-673-2700 - Rau kev pab 612-673-2800 - Hadii aad Caawimaad u baahantahay 612-673-3500.
This application must be stapled and all pages attached to avoid processing delays. Page 1 of 4 - October 2015
#1
FOR OFFICE USE ONLY:
LICENSE ID #:
City of Minneapolis
Licenses and Consumer Services
CSR:
th
350 South 5
Street – Room 1
Minneapolis, MN 55415–1391
FEE: $
Phone: 612-673-2080
DATE:
Fax: 612-673-3399 TTY: 612-673-2157
www.minneapolismn.gov/business-licensing
Trades License Application
1. TYPE OF LICENSE
Building Wrecker, Class A
Heating, Air Conditioning & Ventilation
Residential Specialty Contractor
Building Wrecker, Class B
Oil Burner Installer
Sign Hanger
Duct Cleaner (HVAC Class B)
Plumber
Steam and Hot Water Installer
Gas Fitter
Refrigeration Installer
2. BACKGROUND INFORMATION
Minnesota Sales Tax ID Number, Social Security Number or Individual Tax ID Number
Legal/Corporate Name of Business
Trade Name (DBA)
Business Telephone Number
Business Address/Location
City
State
Zip Code
Mailing Address (if Different than Business Address)
City
State
Zip Code
Name of Person Filling out this Application
Title
Telephone Number
E-Mail Address
Fax Number
Cell Phone Number
Name of Manager and Home Address
Date of Birth
Date of Incorporation
State of Incorporation
Type of Ownership
Corporation
LLC
Sole Proprietor
Partnership
Nonprofit
Is this business publicly traded?
Yes
No
3. QUALIFIED MASTER(S) Attach additional sheets if necessary.
Name of Master
Trade
Comp Card Number
Date of Birth
Name of Master
Trade
Comp Card Number
Date of Birth
Name of Master
Trade
Comp Card Number
Date of Birth
Have you ever had a business license denied or revoked by Minneapolis or another government entity?
Yes
No
If Yes, indicate the date of denial/revocation, government agency, and reason for denial or revocation.
List all types of work to be conducted in Minneapolis.
This application must be stapled and all pages attached to avoid processing delays. Page 2 of 4 - October 2015
4. LIST ALL PARTNERS, OWNERS AND CORPORATE MEMBERS (Attach additional sheets if necessary.)
% of Ownership
Full Name: First, Middle, Last
Date of Birth
Telephone
Home Address
City
State
Zip Code
Full Name: First, Middle, Last
Date of Birth
Telephone
% of Ownership
Home Address
City
State
Zip Code
Full Name: First, Middle, Last
Date of Birth
Telephone
% of Ownership
Home Address
City
State
Zip Code
Have any of the individuals above been convicted of a crime?
Yes
No
If Yes, please provide (or attach) dates and conviction specifics.
5. WORKERS’ COMPENSATION
Workers’ Compensation Company
Policy Number
Coverage Dates
-------Or-------
I certify that I am not required to carry workers’ compensation insurance because:
I am self insured.
I am the sole proprietor and I
have no employees.
I have no employees who are covered by workers’ compensation law. Only employees who are specifically
exempted by statute are not covered by the workers’ compensation law. These include spouse, parents, and children regardless of age.
All other workers whose work is controllable by the employer must be covered.
6. VEHICLES
Will there be vehicles used in the business?
Yes
No (Attach additional sheets if necessary)
Year/Make/Model
Vehicle Company ID
VIN Number
License Plate
Number
Number (State)
7. VERIFICATION
The data you furnish on this application will be used by the City of Minneapolis to assess your qualifications for licensure. Disclosure of
this information is voluntary. You are not legally required to provide this data; however, if you fail to do so, the City of Minneapolis may
be unable to process this application. Disclosure of your Minnesota Tax ID Number, Social Security Number, or Individual Tax ID Number
is required by Minnesota Statutes 270C.72 and your Social Security number may be requested by and released to the Minnesota
Commissioner of Revenue. After submission of this application all information except your Social Security Number will be public
information pursuant to Minnesota Statutes, Chapter 13.
A SIGNATURE IS REQUIRED IN ORDER TO PROCESS THIS APPLICATION
I, (print name) __________________________________________________, certify or declare under penalty of perjury under the laws
of the State of Minnesota that the foregoing is true and correct. All information given is subject to verification by the State of
Minnesota. I understand that false information may result in the denial, suspension or revocation of my business license.
SIGNATURE OF APPLICANT__________________________________TITLE ________________________DATE_____________
This application must be stapled and all pages attached to avoid processing delays. Page 3 of 4 - October 2015
\
#2
City of Minneapolis
Requirements for Insurance Certificates
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
Agency
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
Certificate cannot be pending,
Address
NO RIGHTS UPON THE CERTIFICATE HOLDER.
binder or TBA.
City, State, Zip
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
The Legal/Corporate Name
INSURED
INSURER A:
must match exactly
INSURER B:
(word for word) to the
INSURER C:
Approved Licensee Name
(including Inc, or LLC),
INSURER D:
Trade Name (DBA)
INSURER E:
and address of premises.
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY
POLICY
EFFECTIVE
POLICY
INSR
NUMBER
DATE
EXPIRATION
LTR
TYPE OF INSURANCE
(MM/DD/YY)
DATE (MM/DD/YY)
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
† COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE (Any
$
one fire)
† CLAIMS MADE
MED EXP
$
† OCCUR
(Any one person)
†
PERSONAL & ADV
$
INJURY
†
GENERAL
$
AGGREGATE
GEN’L AGGREGATE LIMIT APPLIES PER:
PRODUCTS –
$
COMP/OP AGG
† POLICY
† PROJECT
† LOC
AUTOMOBILE LIABILITY
COMBINED
† ANY AUTO
$
SINGLE LIMIT
(Ea accident)
† ALL OWNED AUTOS
BODILY INJURY
$
† SCHEDULED AUTOS
(Per person)
† HIRED AUTOS
BODILY INJURY
$
† NON – OWNED AUTOS
(Per accident)
†
PROPERTY DAMAGE
$
(Per accident)
†
AUTO ONLY – (Ea
GARAGE LIABILITY
$
Accident)
OTHER
EA
† ANY AUTO
THAN
ACC
$
AUTO
†
ONLY:
AGG
$
EXCESS LIABILITY
EACH OCCURRENCE
$
† OCCUR † CLAIMS MADE
AGGREGATE
$
$
† DEDUCTIBLE
$
† RETENTION
$
A
WORKER’S COMPENSATION AND EM
X/WC STATUTORY
PLOYER’S LIABILITY
LIMITS / OTHER
E.L. EACH
ACCIDENT
E.L. DISEASE – EA
EMPLOYEE
E.L. DISEASE –
POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS:
ADDITIONAL INSURED; INSURER LETTER
CERTIFICATE HOLDER
City of Minneapolis
Licenses and Consumer Services
AUTHORIZED REPRESENTATIVE
1-C City Hall
Original signature or
350 South 5th Street
stamp of Agent.
Minneapolis, MN 55415
Applications will be returned if requirements are not complete.
This application must be stapled and all pages attached to avoid processing delays. Page 4 of 4 - October 2015
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