HomeMy WebLinkAboutMechContLic-010317CITY OF EDINA
4801 50th Street West, Edina, MN 55424-1394
Building Inspections Division
(952) 826-0372 FAX (952) 826-0389 www.EdinaMN.gov
I.D. NUMBER
for office use only
MECHANICAL CONTRACTOR LICENSE APPLICATION
January 1, 20___ through December 31, 20___
Application is hereby submitted for license to do mechanical work within the City of Edina, Minnesota, in accordance with the ordinances of the City regarding the same.
Firm Name: ____________________________________________________________________________________
Address: _____________________________________________City: ____________________________________
State: ________Zip: ______________Phone Number: _____________________Email:________________________
Name of Owner or Representative: __________________________________________________________________
Address: ___________________________________________City: _______________________________________
State: ________Zip: _______________Phone Number: ____________________Email:________________________
Initial: ____ Renewal: _____ Class A: _____
Provide Certificate of Insurance ($100,000/300,000/50,000)
Statewide Surety Bond required
_______HVAC Installers License ($67.00) _______Steam and Hot Water Installers License ($67.00) _______Refrigeration Installers License ($67.00)
_______Oil Burner Installers License ($67.00) _______Gas Fitter License ($67.00) _______Gas Fireplace/Wood Burning/Free Standing Stoves ($67.00)
_______Stoker License ($67.00)
_______________________________________________________________________________________ Applicants Signature (Please print)
LICENSE APPLICANT:
Pursuant to Minnesota Statute 270.72 tax clearance: Issuance of Licenses, the Licensing authority is required to provide
to 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 1874, 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 ofRevenue. 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 renewalapplication.
Please supply the following information and return along with your application to the agency issuing the License. Do not return to the Department of Revenue.
License Authority: City of Edina, Hennepin County Type of License being applied for or renewed: ________________________Renewal Date: _______________________
PROOF OF WORKER’S COMPENSATION INSURANCE COVERAGE
The Minnesota Statute 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 Worker’s Compensation Insurance coverage requirement of Section 176.181, Subd. 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 put in their company file. It will be furnished,
upon request to the Department of Labor and Industry to check for compliance with Minnesota Statute Sec. 176.181, Subd. 2.
This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is
not provided and/or is falsely reported. Furthermore, if the information is not provided and/or falsely reported, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry,
payable 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 of worker’s compensation.
Insurance Company name: ______________________________________________________(not the insurance agent) Policy number or self-insurance permit number: __________________Coverage Dates: ___________to____________
OR I am not required to have Worker’s Compensation liability coverage because:
( ) I have no employees covered by the Law
( ) Other (specify)_________________________________________________________________________________ I have read and understand my rights and obligations with regards to business licenses, permits and worker’s
compensation coverage, and I certify that the information provided is true and correct.
Business Name:____________________________________________________________________________________
Signature of Applicant: __________________________________________________Date:_______________________
CITY OF EDINA BUILDING DEPARTMENT
Personal Information (if applicable)
Applicant’s Name:__________________________________________________________________________________
Applicant’s Address: ________________________________________________________________________________
City: _________________________________________State: ______________________Zip: _____________________
Business Information (if applicable) Business Address: __________________________________________________________________________________
City: ________________________________________State: _______________________Zip: _____________________
Minnesota Tax Identification Number: __________________________________________________________________
Federal Tax Identification Number: ____________________________________________________________________
If a Minnesota Tax Identification number is not required, please explain:_______________________________________
__________________________________ _____________________________________ _____________________ Signature Position (Officer) Date
APPLICATION FOR LICENSE INVOLVING PRIVATE OR CONFIDENTIAL INFORMATION
(TENNESSEN WARNING)
In connection with your request for a license the city has asked that you provide it with information about yourself which
is classified as either private or confidential by the Minnesota Government Data Practices Act (M.S.A. 13.04). Accordingly, the City is required to inform you of the following:
1.The purpose and intended use of the information requested is: To determine if you are eligible for a licensefrom the City of Edina.
2.You are not legally obligated to supply the requested information.
3.The known consequences of supplying the requested information is: The information, or further investigation coulddisclose information, which could cause your application to be denied.
4.The known consequences of refusing to supply the requested information is: Your request for a license cannot beprocessed.
5.The following persons and entities are authorized by law to receive the information if provided: Staff of Edina Police
Department, Bureau of Criminal Apprehension, Hennepin County Warrant Office, Ramsey County Warrant Office,State of Minnesota - Driver License Section, Hennepin County Auditor, Other governmental agencies necessary to
process your application.
The undersigned, by signing this notice, acknowledges that he/she has read and understood the contents of this notice and
has received a copy of this notice.
Signature:_____________________________________________________________Date:________________________