Fillable CONTRACTOR LICENSE APPLICATION 12800 Ravine Parkway South Cottage (City of Cottage Grove)

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CONTRACTOR LICENSE APPLICATION 12800 Ravine Parkway South Cottage (City of Cottage Grove)

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The CONTRACTOR LICENSE APPLICATION 12800 Ravine Parkway South Cottage (City of Cottage Grove) form is 2 pages long and contains:

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File type: PDF

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BROWSE CITY OF COTTAGE GROVE (MN) FORMS

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12800 Ravine Parkway South
Cottage Grove, MN 55016
(651) 458-2804
(651) 458-2897 FAX
pdillon@cottagegrovemn.gov
www.cottagegrovemn.gov
CONTRACTOR LICENSE
APPLICATION
Application documents will be reviewed for compliance with the requirements of City Code Title 3, Chapter 9 governing Building Contractors
doing business in the City of Cottage Grove. The non-refundable APPLICATION FEE of $50.00 covers the combination of all licenses
for the year. Checks should be made payable to the “City of Cottage Grove” and presented/mailed with this application form to the above
address.
LICENSE(S)* APPLIED FOR:
Blacktop
Concrete/Masonry
Demolition
Driveway
Excavating/Grading
Fire Suppression Systems
Fireplace*
Gas Piping*
General – Commercial Only
General Residential
HVAC*
Landscaping/Lawn Irrigation**
Mechanical*
Pools
Siding*
Windows
Signage*
Sewer & Water***
Other (Please Specify):
*Must include copy of MN State Bond
Please Print **Must include copy of Master Plumber License
***Must include copy of MN Pipe Layers Certificate
Business Name:
Contact Person: Email Address:
Business Address:
Street, Post Office Box
City, State ,Zip
Business Phone(s):
FAX
Cell/
Pager
Business Owner Name:
Business Owner Address:
City, State ,Zip
Business Owner Phone(s):
FAX
Cell/
Pager
Minnesota Tax ID #:
Federal Tax ID:
If a Minnesota tax identification number is not required, please explain:
FOR OFFICE USE ONLY
Building Official: _______________________________ Date: _____________________
DATA PRIVACY NOTICE: The data you supply on this form will be used to assess your qualifications for
the license. You are not legally required to provide this data, but we will not be able to grant the
license without it. If a license is granted, the data you have supplied will constitute a public record
and copies may be issued to anyone requesting them. The required data allows us to distinguish you
from other applicants; to identify you in our license files; to verify that you are the person who applied
for the license; to contact you if any additional information is required; to determine whether you
meet any minimum age requirements; and to determine if any conviction you may have on record
might affect your suitability as a license holder. 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. (See below.)
Please sign below to indicate that you have read this notice.
Signature:
To request that your residence address and telephone number be considered private data, you must
list your alternative address and telephone number below.
Address:
Telephone Number:
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signature
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CC0515 Workers Comp
Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
Licensing and Certification Services
443 Lafayette Road North
St. Paul, MN 55155
Mailing Address:
PO Box 64217
St. Paul, MN 55164-0217
E-mail: dli.license@state.mn.us
Web Site: www.dli.mn.gov/ccld.asp
Directions: http://www.dli.mn.gov/Direct.asp
Phone: (651) 284-5034
Certificate of Compliance
Minnesota Workers’ Compensation Law
This form must be completed by the business license applicant.
Print in ink or type
Minnesota Statutes § 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 Minn. Stat. 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 kept in effect at all times by employers as required by law.
License or certificate number (if applicable)
Business telephone number
Alternate telephone number
Business name (Provide the legal name of the business entity. If the business is a sole proprietor or partnership, provide the owner’s name(s),
for example John Doe, or John Doe and Jane Doe.)
DBA (“doing business as” or “also known as” an assumed name), if applicable
Business address (must be physical street address, no P.O. boxes)
City
State
ZIP code
County
Email address
You must complete number 1 or 2 below.
Note: You must resubmit this form to the authority issuing your license if any of the information you have provided changes.
1. I have a workers’ compensation insurance policy.
Insurance company name (not the insurance agent)
Policy number
Effective date
Expiration date
I am self-insured for workers’ compensation. (Attach a copy of the authorization to self-insure from the Minnesota Department of
Commerce; see www.mn.gov/commerce/industries/insurance/licensing/self-insurance.)
2. I am not required to have workers’ compensation insurance because:
I only use independent contractors and do not have employees. (See Minn. Stat. § 176.043 for trucking and messenger courier
industries; Minn. Stat. § 181.723, subd. 4, for building construction; and Minnesota Rules chapter 5224 for other industries.)
I do not use independent contractors and have no employees. (See Minn. Stat. § 176.011, subd. 9, for the definition of an
employee.)
I use independent contractors and I have employees who are not required to be covered by the workers’ compensation law.
(Explain below.)
I only have employees who are not required to be covered by the workers’ compensation law. (Explain below.) (See Minn.
Stat. § 176.041 for a list of excluded employees.)
Explain why your employees are not required to be covered
I certify the information provided on this form is accurate and complete. If I am signing on behalf of a business, I certify I am authorized to sign
on behalf of the business.
Print name
Applicant signature (required)
Title
Date
If you have questions about completing this form or to request this form in Braille, large print or audio, call (651) 284-5032 or
1-800-342-5354.
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CONTRACTOR LICENSE APPLICATION 12800 Ravine Parkway South Cottage (City of Cottage Grove)

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Completed 21 January 2021

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