City of Edina Form Center

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 Address*
8. City*
9. State*
10. Zip Code*
12. Company Phone Number*
14. Primary License Holder is the person responsible for the company license with DOLI.
16. Primary License Holder Last Name*
17. Primary License Holder First Name*
19. Primary Cell Phone Number*
20. Primary Contact Email *
22. Provide your Minnesota Tax ID Number. If a Minnesota Tax ID Number is not required, explain why. *
23. Provide a Federal Tax ID or Social Security Number.*
25. Application Type*

    1. Initial
    2. Renewal
    3. Class A
26. Provide certificate of insurance ($100,000/$300,000/$50,000)*
27. Provide Statewide Surety Bond*
29. Edina mechanical local licenses are valid for the calendar year in which you apply for them.
31. HVAC Installers License
    HVAC Installers License
32. Price
33. Quantity
35. Shipping Cost
36. Taxable
38. Steam and Hot Water Installers License
    Steam and Hot Water Installers License
39. Price
40. Quantity
42. Shipping Cost
43. Taxable
45. Refrigeration Installers License
    Commercial Refrigeration Installers License (Not for AC Units)
46. Price
47. Quantity
49. Shipping Cost
50. Taxable
52. Oil Burner Installers License
    Oil Burner Installers License
53. Price
54. Quantity
56. Shipping Cost
57. Taxable
59. Gas Fitter License
    Gas Fitter License
60. Price
61. Quantity
63. Shipping Cost
64. Taxable
66. Gas Fireplace/Wood Burning/Free Standing Stoves License
    Gas Fireplace/Wood Burning/Free Standing Stoves License
67. Price
68. Quantity
70. Shipping Cost
71. Taxable
73. Stoker License
    Stoker License
74. Price
75. Quantity
77. Shipping Cost
78. Taxable
82. Proof of Worker's Compensation Insurance Coverage:
84. Insurance Company Name
    Please do not provide the name of the insurance agent.
86. Policy Number
87. Expiration Date
89. 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).
91. Upload a certificate of insurance or permit to self-insure.
93. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

    1. I agree.
95. 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.
97. 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:
99. 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:
101. 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:
103. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.
105. Please confirm you agree to the above.*

     1. I agree.
107. 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.
109. Please confirm you agree to the above Data Practices Act.*

     1. I agree.
111. Alternate Address
112. Alternate Phone
114. Electronic Signature:
116. Name*
117. Position or Officer*
Leave This Blank:


118. Calculate Totals Proceed to Checkout

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