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2. Application Fee: $80 (license period: expires 1 year from date of approval)

   Please do not fill out and submit this form unless you are a mechanical contractor and are certain it is required or you have been asked by city staff. If you are unsure, please call 651-638-2043.

   Note: The license shall not be valid until a Certificate of Insurance (COI) is furnished showing workers' compensation coverage (workers compensation insurance requirements may be waived if the applicant is self-employed) and liability coverage in the amount of $300,000 per person, $300,000 per occurrence, $500,000 per accident and $100,000 per property damage.

   Please submit current certificate/coverage using the file upload on this form.

4. Name of Company*
5. Phone Number*
7. Contact Person*
8. Email Address*
10. Business Address*

    Must be a physical address: no P.O. boxes.

12. City*
13. State*
14. Zip Code*
16. State Bond Number (if applicable)
17. State Bond Number Expiration Date
    State Bond Number Expiration Date
19. Certificate of Liability Insurance / Workers Compensation or any other documents*
20. Liability - Name of Insurance Company*

    (Not the insurance agent)

22. Type of work to be performed*

    1. Concrete/Masonry
    2. Commercial
    3. Heating, Ventilation, and Air Conditioning (HVAC)
    4. Excavators
    5. Waterproofers
    6. Roofers
    7. Gas Fitters
    8. Other
23. If your company is "doing business as" (DBA) or also known as another name, please enter it
25. Liability Insurance Expiration*
    Liability Insurance Expiration
27. Minnesota Statues

    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 Statues, 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 (if applicable) must be kept in effect at all times by employers as required by law.

29. I understand that I must fill out the following information about Workers' Compensation*

    1. Yes
30. Select One*

    1. I have Workers' Compensation
    2. I am not required to have Workers' Compensation
32. Workers' Comp - Name of Insurance Company*

    (Not the name of the insurance agent)

34. Workers' Compensation Effective Date*
    Workers' Compensation Effective Date
35. Workers' Compensation Expiration Date*
    Workers' Compensation Expiration Date
37. I am not required to have Workers' Compensation because:*
    -- Select One --I have no employeesI am self-insured for workers' compensationI have employees but they are not covered by the workers' compensation law (See Minn. Stat. 176.041 for a list of excluded employees)Other
39. Policy Number
41. Upload a copy of authorization to self-insure from the Minnesota Department of Commerce*
43. Explain why your employees are not covered*
45. If you selected other, please explain*
47. Accepted by*

    (Enter name.)

    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.

48. My payment will be by*

    1. Check
    2. Credit Card
50. If your permit was put on hold for expired city license, please give the address:
52. State licensing questions may be directed to:

    Minnesota Department of Labor and Industry
    P.O. Box 64228
    St. Paul, MN 55164
    Department of Labor and Industry website

    Licensing and Certification Services
    Email Licensing and Certification Services
    Phone: 651-284-5034
    Fax: 651-284-5743

54. Data Practices Advisory (Tennessen Warning):

    Some or all of the information that you are asked to provide on this form is classified by state law as either private or confidential. Private data is information that generally cannot be given to the public but can be given to the subject of the data. Confidential data is information that generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to comply with MN Statute § 270c.72, which requires the city to provide the MN Department of Revenue with federal tax identification numbers, state tax identification numbers and social security numbers for all professions, occupations, trades and businesses licensed by the city or whose license is registered with the city. You are legally required to provide this information. If you refuse to supply the information, your license application may be delayed or denied. Persons or entities authorized by law to receive this information include city staff members whose job requires them to access in order to process your application, law enforcement officers who are implementing the New Brighton Crime-Free Housing Program and other initiatives as well as the MN Department of Revenue.

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56. Submit

* indicates a required field