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*

5. Jan. 1-Dec. 31
   -- Select One --201820192020

7. Company Phone Number*

8. Company Email Address*

10. Company Address*

12. City*

13. State*

14. Zip Code*

16. Name of Owner or Representative*

18. Owner Phone Number*

19. Owner Email Address*

21. Owner Address*

23. City*

24. State*

25. Zip Code*

27. Applicant Name*

29. Applicant Phone Number*

30. Applicant Email Address*

32. Applicant Address*

34. City*

35. State*

36. Zip Code*

38. Business Information, if applicable or different:

40. Business Phone Number*

41. Business Email Address*

43. Business Address

45. City

46. State

47. Zip Code

49. Provide your Minnesota Tax ID Number. If a Minnesota Tax ID Number is not required, explain why. *

50. Provide a Federal Tax ID or Social Security Number.*

52. Application Type*

    1. Initial
    2. Renewal
    3. Class A

53. Provide certificate of insurance ($100,000/$300,000/$50,000)*

54. Provide Statewide Surety Bond*

56. HVAC Installers License

    HVAC Installers License

57. Price

58. Quantity

60. Shipping Cost

61. Taxable

63. Steam and Hot Water Installers License

    Steam and Hot Water Installers License

64. Price

65. Quantity

67. Shipping Cost

68. Taxable

70. Refrigeration Installers License

    Commercial Refrigeration Installers License (Not for AC Units)

71. Price

72. Quantity

74. Shipping Cost

75. Taxable

77. Oil Burner Installers License

    Oil Burner Installers License

78. Price

79. Quantity

81. Shipping Cost

82. Taxable

84. Gas Fitter License

    Gas Fitter License

85. Price

86. Quantity

88. Shipping Cost

89. Taxable

91. Gas Fireplace/Wood Burning/Free Standing Stoves License

    Gas Fireplace/Wood Burning/Free Standing Stoves License

92. Price

93. Quantity

95. Shipping Cost

96. Taxable

98. Stoker License

    Stoker License

99. Price

100. Quantity

102. Shipping Cost

103. Taxable

107. Proof of Worker's Compensation Insurance Coverage:

109. Insurance Company Name

     Please do not provide the name of the insurance agent.

111. Policy Number

112. Expiration Date

114. 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).

116. Upload a certificate of insurance or permit to self-insure.

118. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

     1. I agree.

120. 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. <br/><br/> 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: <ol><li>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:</li> <li>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:</li> <li>3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.</li></ol>

     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. 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. 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. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.

122. Please confirm you agree to the above.*

     1. I agree.

124. 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.

126. Please confirm you agree to the above Data Practices Act.*

     1. I agree.

128. Alternate Address

129. Alternate Phone

131. Electronic Signature:

133. Name*

134. Position or Officer*

Leave This Blank:


135. Calculate Totals Proceed to Checkout

* indicates a required field