Government data practices act Tennessen warning: The data you supply on this form will be used to process the license you are applying for.
You are not legally required to provide this data, but we may not be able to process the license without it. The data will constitute a public record if and when the license is granted.
Is this property licensed by a state agency? Please see Ordinance 3-28-5: EXCEPTION (B) Yes No
Rental address _______________________________________________________ License No. __________________
I am renewing this rental license I am not renewing this license
License Process: Fill out this application completely and enclose the appropriate license fee. (All fees and a link to rental standards are listed on the reverse
side of this application).
Failure to enclose the proper fee and complete the MN Workers Compensation and Tax Id section, will result in the application
returned to you and delay the processing of your rental business license.
Once complete, upload signed application and pay fees at or return to Burnsville City Hall
Email to schedule a rental inspection. Rental inspections are required every three years
If paying by check, make payable to the City of Burnsville
Sign, date and return the completed application online at or to Burnsville
City Hall, 100 Civic Center Parkway,
Burnsville, MN 55337.
I understand that it is my responsibility to submit all required fees and obtain all necessary approvals prior to licensing. I acknowledge that I am the owner of record or
agent for this property and am authorized to sign this application.
By signing this application I am acknowledging and agreeing to uphold the rental standards as
of my rental license. All information is correct and accurate to the best of my knowledge.
Applicant name _________________________________________________________________________________________________________
(please print) First Middle L
Signature ____________________________________________________________________________ Date _____________________________
The rental license standards and online instructions can be found at this link at
Business name (if applicable) ______________________________
Owner name __________________________________________
Owner address ________________________________________
City_______________________ State ______ Zip __________
Owner phone __________________ Cell __________________
Owner email*_______________________________________
*Email addresses are optional. This information may be considered public record and may be made
available upon request.
(The agent named below is authorized to make or order repairs and/or service to the
building, to provide required services necessary to protect the health, safety and welfare
of the occupants or is able to contact the person so authorized)
Property Mgmt. Company __________________________________
Attn ___________________________________________________
Address ________________________________________________
City______________________ State _______ Zip____________
Phone ______________________ Cell _____________________
Email: __________________________________________________
Pursuant to *Minnesota Statute 270C.72 Tax Clearance: (
See reverse side) License No. _____________________________________
Sole Proprietors only: Partnerships, LLCs, And Corporations: (mandatory)
Social Security Number ______________________________
(mandatory) Minnesota Tax ID Number __________________
If a Minnesota Tax Identification Number is not required, please explain below.
ID Number ________________________
Minnesota Statutes, Section 176.182 (
See reverse side)
INSURANCE COMPANY NAME (not the insurance agent) ____________________________________________________________________________
COMPENSATION INSURANCE POLICY NO. ________________________________
Dates of coverage _________________
SELF INSURED: I have attached a copy of the permit to self-insure.
THIS PORTION IF EXEMPT: I am not required to have workers compensation insurance coverage because:
I have no employees
I have employees but they are not covered by the workers compensation law. (See Minn. Stat. § 176.041for a list of excluded employees.)
Explain why your employees are not covered: ________________________________________________________________________________
FOR CITY USE ONLY: Amount/Ck# _________ Rental License Region Inspection Scheduled _____________ S C
Passed Inspection Provisional License Mailed _________ Rental License Mailed /emailed ______________
click to sign
click to edit
Assistance or paper copies may be requested by emailing or by calling 952-895-4440.
It is the responsibility of the owner or owner’s agent to renew the rental license on or before the due date. Failure to obtain a
rental license or allowing the license to expire can result in a citation and fine of up to $1000.
License exemptions can be located at in City Code 3-28-5.
License fees are not refundable or transferable.
Please email our office at
to schedule a rental inspection. Inspections must occur during regular
business hours. Please notify tenants in advance of upcoming rental inspections.
If there are items noted during the inspection that are not in compliance with City ordinances, they shall be corrected prior to
the issuance of the business license. It is the responsibility of the owner or owner’s agent to schedule all re-inspections.
Additional inspections beyond the re-inspection may be charged at an additional $185. This is a separate fee and is not applied
toward your license fee. After the property has been determined to be in compliance with City ordinances the license will be issued.
Some correction may require a building permit. Please call 952-895-4444 to verify building ordinance requirements.
The City of Burnsville provides general information, updates and notices via email subscription. Sign up to receive notices at This includes notifications of any proposed
ordinances at least 10 days before the City
Council conducts a final vote on the proposed ordinance. (M.S. 415.19)
Multi-family dwellings
$160/building and $15/per unit
(apartments, independent, coop, assisted living)
Multi-family townhome
(entire building owned by same owner)
Manufactured home park
(owned by the park)
Annual fire inspection
Inspection fee
Missed inspection fee (“No show”)
$100/building and $15/per unit
$ 285 plus $60/ per unit
$160 (per building)
$185 (per building)
Late fees
Submitted 15-29 days after due date: 25% of license base fee
Submitted 30-45 days after due date: 50% of license base fee
Submitted 45 days after due date: 100% of license base fee
2018 Minnesota Statutes 270C.72 TAX CLEARANCE; ISSUANCE OF LICENSES. Subd. 4. Licensing authority; duties. Licensing
authority; duties. All licensing authorities must require the applicant to provide the applicant's Social Security number or individual
taxpayer identification number and Minnesota business identification number, as applicable, on all license applications. Upon
request of the commissioner, the licensing authority must provide the commissioner with a list of all applicants, including the name,
address, business name and address, and Social Security number or individual taxpayer identification number and business
identification number, as applicable, of each applicant. The commissioner may request from a licensing authority a list of the
applicants no more than once each calendar year.
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 or engage in any activity in Minnesota until the applicant presents acceptable evidence of
compliance with the workers' compensation insurance coverage requirement of Minnesota Statutes, Chapter 176. The required
compensation insurance information is the name of the insurance company, the policy number, and the dates of coverage,
or the permit to self-insure. 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.