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Plumbing, Sewer and Water Contractor Registration
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Application is hereby submitted for license to do plumbing work within the City of Edina and to make connections with the water mains and sewers of the City in accordance with the ordinances of said City regulating the same.
Company Phone Number
Provide your Minnesota Tax ID Number. If a Minnesota Tax ID Number is not required, explain why.
Provide a Federal Tax ID or Social Security Number.
Provide a Certificate of Insurance ($300,000/$100,000/$50,000)
Provide a State Plumbing Bond or State Water Softener Bond
Provide a State Master Plumbing License, Pipelayer Certificate or Water Softener License.
If partnership, list the name and address of each partner. If corporation, list name and address of principal officers.
First Partner Name
First Partner Address
Second Partner Name
Second Partner Address
Upload additional names, if needed.
Applicant's State License Number
State License Number Expiration Date
State License Number Expiration Date
Proof of Worker's Compensation Insurance Coverage:
Insurance Company Name
Please do not provide the name of the insurance agent.
I am not required to have workers' compensation liability coverage because:
I have no employees.
I am self-insured (include permit to self-insure below).
I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children, and certain farm employees).
Upload a certificate of insurance or permit to self-insure.
I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.
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 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 confirm you agree to the above.
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 signature on 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.
Position or Officer
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