2021 Contractor Requirement Form A,bertvill-c
Smoli'Iown Living.Big Cay Life.
2021 PLUMBING, MECHANICAL,AND GAS FITTER REQUIREMENTS
Name/DBA:
Business Address:
Business Phone: Cell:
Business Fax:
Email:
GAS FITTER REQUIREMENTS
❑ A current public liability insurance certificate of$100,000 per person and $300,000 per
accident for bodily injury and $100,000 for property damage. (Enclose a current
certificate)
❑ Proof of$25,000 bond with the Department of Administration as required by Minnesota
Statute 326.992
❑ Certificate of Compliance, Minnesota Worker's Compensation Law form completed
annually
❑ A$35.00 processing fee
HEATING REQUIREMENTS
❑ Proof of$25,000 bond with the Department of Administration as required by Minnesota
Statute 326.92
PLUMBING REQUIREMENTS
❑ Minnesota plumbing license, the City must have a copy of the Master Plumber license
for 2021. (Enclose a copy of the Master Plumber License card)
❑ Proof of$25,000 plumbing bond
REMINDER: No permits or inspections will be issued until all current requirements are
met.
Applicant Signature: Date:
Print Applicant Name:
CITY OF ALBERTVILLE 5959 MAIN AVENUE NE 763.497.3384 x103
BUILDING DEPARTMENT ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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A,bertvill-c
Smoil°1frrum Living.Big Cay Life.
LIC 04(3/13)
(GAS FITTER EQUIRED)
Certificate of Compliance
Minnesota Workers' Compensation Law
THIS FORM MUST BE COMPLETED BY THE BUSINESS LICENSE APPLICANT
PRINT IN INK or TYPE.
Minnesota Statutes,Section 176.182 requires every state and local licensing agency to withhold the issuance or
renewal of a license or permit to operate a business in Minnesota until the applicant presents acceptable
evidence of compliance with the workers'compensation insurance coverage requirement of Minnesota Statutes,
Chapter 176.If the required information is not provided or is falsely stated,it shall result in a$2,000 penalty
assessed against the applicant by the Commissioner of the Department of Labor and Industry.
A valid workers'compensation policy must be ke tin effect at all times by employers as required bylaw.
LICENSE or CERTIFICATE NO(if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE NO.
BUSINESS NAME(Use the person(s)name if business structure is sole proprietor or partnership(i.e.,John Doe,or John Doe and Jane Doe),
otherwise it is the legal name of the business entity.)
DBA("doing business as"or also known as an assumed name)(if applicable)
BUSINESS ADDRESS(must be physical street address,no PO boxes) CITY STATE ZIP CODE
COUNTY EMAILADDRESS
YOUR LICENSE OR CERTIFICATE WILL NOT BE ISSUED WITHOUT THE
FOLLOWING INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 - Workers' compensation insurance policy information
INSURANCE COMPANY NAME(not the insurance agent) NAIC Number
POLICY NO. EFFECTIVE DATE EXPIRATION DATE
NUMBER 2 - Reason for exemption from workers' compensation insurance
If you have questions regarding the need to obtain workers'compensation coverage,including exemptions,
contact 651.284.5032 or 1-800-342-5354.
❑ I have no employees. (See Minn.Stat.§ 176.011,subd.9 for the definition of an employee.)
❑ I am self-insured for workers'compensation(attach a copy of the authorization to self-insure from the
Minnesota Department of Commerce).
❑ I have employees but they are not covered by the workers'compensation law. (See Minn.Stat§ 176.041
for a list of excluded employees.) Explain why your employees are not covered:
❑ Other:
I certify that the information provided on this form is accurate and complete.If I am signing on behalf of a business,I certify
that I am authorized to sign on behalf of the business.
PRINT NAME
APPLICANT SIGNATURE(required) TITLE DATE
CITY OF ALBERTVILLE 5959 MAIN AVENUE NE 763.497.3384 x103
BUILDING DEPARTMENT ALBERTVILLE,MN 55301 WWW.CI.ALBERTVILLE.MN.US
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