City of Edina Form Center

Mechanical Contractor License Application

2. 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.
4. Company Name*
6. Company Phone Number*
7. Company Email Address*
9. Company Address*
11. City*
12. State*
13. Zip Code*
15. Name of Owner or Representative*
17. Owner Email Address*
19. Provide your Minnesota Tax ID Number. If a Minnesota Tax ID Number is not required, explain why. *
20. Provide a Federal Tax ID or Social Security Number.*
22. Application Type*

    1. Initial
    2. Renewal
    3. Class A
23. Provide certificate of insurance ($100,000/$300,000/$50,000)*
24. Provide Statewide Surety Bond*
26. HVAC Installers License
    HVAC Installers License
27. Price
28. Quantity
30. Shipping Cost
31. Taxable
33. Steam and Hot Water Installers License
    Steam and Hot Water Installers License
34. Price
35. Quantity
37. Shipping Cost
38. Taxable
40. Refrigeration Installers License
    Commercial Refrigeration Installers License (Not for AC Units)
41. Price
42. Quantity
44. Shipping Cost
45. Taxable
47. Oil Burner Installers License
    Oil Burner Installers License
48. Price
49. Quantity
51. Shipping Cost
52. Taxable
54. Gas Fitter License
    Gas Fitter License
55. Price
56. Quantity
58. Shipping Cost
59. Taxable
61. Gas Fireplace/Wood Burning/Free Standing Stoves License
    Gas Fireplace/Wood Burning/Free Standing Stoves License
62. Price
63. Quantity
65. Shipping Cost
66. Taxable
68. Stoker License
    Stoker License
69. Price
70. Quantity
72. Shipping Cost
73. Taxable
77. Proof of Worker's Compensation Insurance Coverage:
79. Insurance Company Name
    Please do not provide the name of the insurance agent.
81. Policy Number
82. Expiration Date
84. I am not required to have workers' compensation liability coverage because:

    1. I have no employees.
    2. I am self-insured (include permit to self-insure below).
    3. I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children, and certain farm employees).
86. Upload a certificate of insurance or permit to self-insure.
88. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

    1. I agree.
90. 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.
92. 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:
94. 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:
96. 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:
98. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.
100. Please confirm you agree to the above.*

     1. I agree.
102. THE MINNESOTA DATA PRACTICES ACT requires that we inform you of your rights about the private data we are requesting on this form. Private data is available to you, but not to the public. We are requesting this data to determine your eligibility for a license from the City of Edina. Providing the data may disclose information that could cause your application to be denied. You are not legally required to provide the data, however, refusing to supply the data may cause your license to not be processed. Under MS 270.72, the City of Edina is required to provide the Minnesota Department of Revenue your MN Tax ID Number or Social Security Number. This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest. The Department of Revenue may supply information to the Internal Revenue Service. In addition, this data can be shared by Edina City Staff, the State of Minnesota Driver License Section, Hennepin County Auditor, Bureau of Criminal Apprehension, Hennepin County Warrant Office, and Ramsey County Warrant Office. Your submission of this application indicates you understand these rights. Your residence address and telephone number will be considered public data unless you request this information to be private and provide an alternative address and telephone number below.
104. Please confirm you agree to the above Data Practices Act.*

     1. I agree.
106. Alternate Address
107. Alternate Phone
109. Electronic Signature:
111. Name*
112. Position or Officer*
Leave This Blank:


113. Calculate Totals Proceed to Checkout

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