City of Edina Form Center

2. 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.
4. Your contractor information will be reviewed and updated within half a business day.
6. Company Name*
8. Company Address*
10. City*
11. State*
12. Zip Code*
14. Company Phone Number*
16. Primary License Holder Last Name*
17. Primary License Holder First Name*
19. Primary Contact Cell Phone Number*
20. Primary Contact Email *
22. Provide a Certificate of Insurance ($300,000 / $100,000 / $50,000) and Workers' Compensation (if applicable)*

    Upload accepts multiple file types

24. Plumber Contractor State License Number*
25. Plumber Contractor License Expiration Date*
27. State Master Plumbing License, Pipelayer Certificate or Water Softener License

    License number

28. License or Certificate Expiration Date
30. Master Plumber's Name
32. 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).
34. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

    1. I agree.
38. 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.
40. 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:
42. 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:
44. 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:
46. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.
48. Please confirm you agree to the above. *

    1. I agree.
50. 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. *

    1. I agree.
52. Alternate Address
53. Alternate Phone
55. Electronic Signature:
57. Name*
58. Position or Officer*
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field