Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette

Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198

Notice to Out-of-State Applicants

If you are planning on opening a dealership in Minnesota and the business will not be a new business operated solely in Minnesota, we require that the application form be completed with the address for the out-of-state location as your main business address and then set up a “subagency” in Minnesota. To do this, you must complete the “Subagency Application” (LIC MS 10) included in this packet of information. Be sure to include appropriate fees for both applications. If you have any questions, please feel free to call this division at (651) 284-5849.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIALDLI) Voice or TDD (651) 297-4198.

Instructions LIC MS 10 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198

Application Instructions for Minnesota Manufactured Home Dealer License

Read laws Chapter 327B before proceeding. The applicant must have two years of experience working for a licensed manufactured home dealer, Minnesota or another state equivalent laws. The applicant must be the owner, partner, or the corporate president for the business that is being licensed. Before filing out application, read instructions for each section. Applicants from outside of Minnesota who desire to obtain a dealer license should list their out-of-state location as their main business location (MS0504), and then list each location in Minnesota as a sub-agency (MS0514). Records shall be available at a single Minnesota location designated by the dealer. GENERAL INFORMATION A. If your business is a partnership – LLC or a corporation, submit photocopy of the Proof of Partnership or Certificate of Incorporation. B. If you are using a name that is part of a corporation, such as Super Homes, Inc. d/b/a XYZ Manufactured Homes, both names must be shown on the application and the surety bond. C. If your business name is other than your first and last name and middle initial, furnish proof of filing an assumed name with the Minnesota Office of the Secretary of State, Minnesota State Retirement Building, 60 Empire Drive, St. Paul, MN 55103, (651) 296-2803, www.sos.state.mn.us. D. Minnesota Tax Identification Number, www.taxes.state.mn.us/ E. Attach a photo of the exterior of the established place of business at the top of the application in space provided. F. If the applicant will be selling new manufactured homes, submit a copy of manufacturer’s sales agreement (franchise or contract) for each make of manufactured home you propose to deal in. G. If the applicant will be brokering used manufactured homes, submit completed trust account information (LIC MS 05). H. Review the Surety Bond (LIC BD 05), verifying that the following information has been provided: 1. Bond number and effective date of the bond completed in upper right hand corner. 2. Identical business name to that on application. 3. Completion of appropriate acknowledgement. 4. Line asking Principal – restate the business name as above. 5. Signature and Title line under Principal – signature of the Applicant as Owner, Partner or Corporate President and title of applicant. 6. Line asking Surety – provide the Surety Company name. 7. Signature line under Surety – signature of the authorized person for Surety Company. 8. Witness – Signatures of witnesses to signatures of Principal and Surety. 9. Acknowledgements – Notary verification of signatures Individual, Partnership, or Corporate company. One of these must be completed. An LLC is considered a partnership. The Surety Acknowledgement must also be completed. I. Furnish a photocopy of valid warranty deed, contract for deed, or lease for a term of at least one year, for the premises housing the established place of business. J. When your place of business is a manufactured home you must show ownership by providing us with a Copy of the Title for the home (not a Certificate of Origin). If the manufactured home is to be considered as real property provide proof that the Title has been surrendered to the State or County and that the manufactured home is being taxed as real estate. K. If the manufacture home display area is not part of the same property as your established place of business, submit photo and map to indicate its relationship to the established place of business. SECTION I Self-explanatory. SECTION II When furnishing any additional information, use 8 1/2 x 11” paper. Identify sheet(s) by company name. SECTION III Self-explanatory.

Instructions LIC MS 02 (11/07)

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SECTION IV Parts A, B, C and D are self-explanatory. Make photocopies of “Salesperson List” blank form. Keep blank original in your records for making future copies. Fill in names of salespersons on a copy of the original. Make a photocopy for your records and submit the completed form with application to the Department of Labor and Industry, Construction Codes and Licensing Division. Include your name on list if you are personally selling manufactured homes at a business located in Minnesota. SECTION V Check for completeness. Signature must be notarized. For fee see “License Application and Service Fee” schedule below. Before mailing, review the application documents to verify that all the required information is included and all the documents and information required as complete. Make a copy of everything for your file. Keep this sheet with your records for reference. Manufactured Home Dealer’s License Service Fee Schedule (Minn. Rules 1350.8200 Fees) Initial License (Principal Location) Initial License (Sub-agency Location) License Bi-Annual Renewal (2 years) 1. Principal Location 2. Sub-agency Location Change Bonding Company Reinstating Bond after Cancellation Duplicate License Checks Returned Without Payment Change of Address Change of Ownership or Application $200.00 $40.00 $400.00 $80.00 $10.00 $10.00 $10.00 $15.00 $10.00 New Application Required Price list effective June 26, 2000

NOTE: Application fees will not be returned after the application has been processed even though the license might not have been issued. Make checks payable to: Department of Labor and Industry.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

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Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied. STAPLE PHOTO OF BUSINESS LOCATION HERE

Reset

Application for Manufactured Home Dealer License

See enclosed instruction sheet. DATE ISSUED PAID CHECK NO. LICENSE NO.

Office Use Only

DATE RECEIVED

The information provided on this form and any required attachments will be used to determine whether the applicant meets the license requirements. Failure to provide the requested information may delay the processing of the application or may be grounds for denying the application. Data provided on the application and attachments is public except for data provided on individuals, which under M.S. § 13.41 is private data (excluding name and mailing address) while the application is pending. Individuals are required to provide their social security numbers pursuant to M.S. § 270C.72, Subd. 4, before a license may be issued. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Individual’s applicant information becomes public data (except the individual’s social security number) and part of the agency’s permanent records once the license is issued. Failure to disclose any material information or false or misleading statement with respect to any material fact required herein is cause to deny, suspend or revoke license. IN COMPLIANCE WITH THE PROVISIONS OF MINNESOTA STATUTES REGULATING MANUFACTURED HOME DEALERS, I AM APPLYING FOR A LICENSE AUTHORIZING ME TO ENGAGE IN BUSINESS AS A MANUFACTURED HOME DEALER. IN SUPPORT OF THIS APPLICATION, I MAKE THE FOLLOWING STATEMENTS UNDER OATH. I will be: (check applicable box or boxes) Brokering or Listing Used Manufactured Homes Selling New Manufactured Homes Selling Used Manufactured Homes

SECTION I USE OF ANY BUSINESS NAME OTHER THAN GIVEN, REQUIRES A SEPARATE LICENSE. I state that the following established place of business is located in an area where zoning regulations allow commercial activity.
VERIFIED BY (name of local zoning administrator) DATE

Check applicable box:

I own this business location

I have one year minimum lease

APPLICANT’S NAME (must be owner, partner, or corporate president)

NAME OF BUSINESS TO BE LICENSED

MN STATE TAX ID NO.

MAIN OFFICE BUSINESS ADDRESS (number and street)

PHONE NO.

CITY

STATE

ZIP CODE

COUNTY

NAME OF MANAGER

MANAGER’S HOME PHONE NO.

MANAGER’S HOME ADDRESS

CITY

STATE

ZIP CODE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

LIC MS 02 (11/07)

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SECTION II Minnesota Statutes § 270C.72, Tax Clearance; Issuance of Licenses, requires the Department of Labor and Industry to require contractor license applicants to provide their Minnesota Identification Number and the social security numbers of all individual owners, partners, officers, and members of the business entity. The Department of Revenue may order the Department to revoke or not issue the license of any applicant who has not filed tax returns or is delinquent in paying taxes. An individual’s social security number is classified as private data and will only be supplied to the Minnesota Department of Revenue, which may supply this information to the Internal Revenue Service, or may occur as authorized or required by law. Failure to supply the required information may delay or prevent the Department from processing the original or renewal application.

If the business is an Individual, partnership, corporation, foreign corporation or a limited liability company, the names, addresses, social security numbers, and signatures of all additional owners, partners, officers, or members must be completed on this form. Please copy this form if you need additional space.

LIST ALL Owners, Officers, Partners, or Members
LAST NAME FIRST NAME MI % OF OWNERSHIP SOCIAL SECURITY NO (mandatory)

RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NO.

APPLICANT SIGNATURE

TITLE (owner, partner, officer or member, etc.)

DATE

LAST NAME

FIRST NAME

MI

% OF OWNERSHIP

SOCIAL SECURITY NO (mandatory)

RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NO.

APPLICANT SIGNATURE

TITLE (owner, partner, officer or member, etc.)

DATE

LAST NAME

FIRST NAME

MI

% OF OWNERSHIP

SOCIAL SECURITY NO (mandatory)

RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NO.

APPLICANT SIGNATURE

TITLE (owner, partner, officer or member, etc.)

DATE

LAST NAME

FIRST NAME

MI

% OF OWNERSHIP

SOCIAL SECURITY NO (mandatory)

RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NO.

APPLICANT SIGNATURE

TITLE (owner, partner, officer or member, etc.)

DATE

LAST NAME

FIRST NAME

MI

% OF OWNERSHIP

SOCIAL SECURITY NO (mandatory)

RESIDENTIAL ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NO.

APPLICANT SIGNATURE

TITLE (owner, partner, officer or member, etc.)

DATE

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SECTION III PROOF OF IDENTITY Attach photocopy of current Minnesota Driver’s License or other current identification showing photo and signature, within dotted lines at right.

APPLICANTS QUALIFICATIONS Education:

Work experience:

Experience in related field:

Business history for last five years (give dates):

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SECTION IV (check applicable boxes below) A. Are you or any person named in Section II 1) affiliated with any other Manufactured Home Dealer or Manufactured Home Manufacturer? 2) out of trust with any bank or lending institute? 3) in arrears in fees, taxes or penalties with any Minnesota state agency? 4) bankrupt or insolvent? B. Do you or any person named in Section II, have: 1) any unsatisfied court judgments? 2) any license as a Manufactured Home Dealer or Manufactured Home Manufacturer, either directly or indirectly, in this or any other state? C. Have you or any person named in Section II ever: 1) been out of trust with any bank or lending institution within the last five years? 2) been adjudged bankrupt or insolvent? 3) had a Manufactured Home Dealer License suspended or revoked in this or any other state? If one or more answers are yes to the above questions, attach sheet of particulars. D. Complete a salesperson list form (LIC MS 04). See instructions before filing out. E. A separate license and fee is required for each subagency. Complete Application for Subagency License (LIC MS 10). A COPY OF THIS APPLICATION AND ACCOMPANYING DOCUMENTS SHALL BE KEPT IN YOUR DEALER FILE. TO AVOID DELAY OR LATE PENALTY, CHECK THAT ALL DOCUMENTS AND FEE AMOUNT(S) IS/ARE INCLUDED BEFORE MAILING. SECTION V I HAVE READ AND UNDERSTAND THE LAWS REGULATING THE SALE OF MANUFACTURED HOMES IN THE STATE OF MINNESOTA.
SIGNATURE OF APPLICANT TITLE

Yes Yes Yes Yes

No No No No

Yes Yes

No No

Yes Yes Yes

No No No

STATE OF

COUNTY OF

On this day of appeared before me, a Notary Public, and being first duly sworn says he/she is the applicant; that he/she has read the application and accompanying exhibits, and that the contents thereof are true to his/her knowledge.

NOTARIAL SEAL Notary Public signature

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Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198

Verification of Applicant’s Experience
PRINT IN INK or TYPE your responses.

The information provided on this form and any required attachments will be used to determine whether the applicant meets the license requirements. Failure to provide the requested information may delay the processing of the application or may be grounds for denying the application. Data provided on the application and attachments is public except for data provided on individuals, which under M.S. § 13.41 is private data (excluding name and mailing address) while the application is pending. Individuals are required to provide their social security numbers pursuant to M.S. § 270C.72, Subd. 4, before a license may be issued. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Individual’s applicant information becomes public data (except the individual’s social security number) and part of the agency’s permanent records once the license is issued. Requirement of Minnesota Statute Chapter 142 of the Laws of 1983 Amending Section 327B.04, subd. 4 of Minnesota Statutes of 1982 which states, “ . . . evidence of having had at least two years’ prior experience in the sale of manufactured homes, working for a licensed dealer.” Effective May 13, 1983. APPLICANT FIRST NAME MIDDLE INITIAL LAST NAME

I, the applicant, have had a minimum of two years experience in the sale of manufactured homes, working for a licensed dealer.
BUSINESS NAME OF DEALER

STREET ADDRESS

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

FROM (month/day/year) DATES OF EMPLOYMENT:

TO (month/day/year)

If you did not work for two years for the above dealer, fill out spaces below so the required two years employment is shown.
BUSINESS NAME OF DEALER

STREET ADDRESS

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

FROM (month/day/year) DATES OF EMPLOYMENT: BUSINESS NAME OF DEALER

TO (month/day/year)

STREET ADDRESS

TELEPHONE NUMBER

CITY

STATE

ZIP CODE

FROM (month/day/year) DATES OF EMPLOYMENT:

TO (month/day/year)

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. LIC MS 03 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5080 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198 E-mail: DLI.License@state.mn.us www.doli.state.mn.us/license.html
PRINT IN INK or TYPE

Manufactured Home Dealer Bond
BOND NO. AMOUNT EFFECTIVE DATE

$20,000

KNOW ALL MEN BY THESE PRESENTS: THAT (Business name as registered with the Office of the Secretary of State) (DBA, doing business as name if applicable) With business office at (Business address, City, State, Zip Code, Telephone number) as PRINCIPAL, and (Surety Company Name) (Surety Company Address, City, State, Zip Code, Telephone number) A corporation duly organized in the state of ______________________ and authorized to do business in the state of Minnesota, as Surety, their successors, assigns, and legal representatives are held and firmly bound, jointly and severally, to the State of Minnesota and any third party sustaining injury within the terms of this bond for payment in the amount of

TWENTY THOUSAND DOLLARS ($20,000), as provided in M.S. 327B.04, subd. 4c. This bond is exclusively for the purpose of reimbursement of consumer customer claims, pursuant to M.S. 327B.11.
The condition of this obligation is that the Principal has applied for a Minnesota Manufactured Home Dealer license to be issued upon the furnishing of this bond, if the Principal faithfully complies with all of the statutes of the State of Minnesota, regulating or being applicable to the business of the Principal as a manufacturer of manufactured homes and indemnifies any person dealing or transacting business with the Principal in connection with any manufactured home from any loss or damage occasioned by the failure of the Principal to comply with any of the laws of the State of Minnesota, then no obligation under this bond shall accrue; otherwise, this obligation shall remain in full force and effect. The terms of this bond shall be continuous and shall constitute a new obligation in the sum of $20,000 for each annual license period for which the Principal is licensed, provided, however, that the aggregate liability for the Surety to all persons for any one annual license period shall in no event exceed the sum of $20,000. The Surety Company shall notify the Department of Labor and Industry, Construction Codes and Licensing Division, in writing prior to payment of any claim against this bond. If, within 10 days of receipt of notification, the Department of Labor and Industry does not object in writing, the claim may be paid. M.S. 327B.11, Subd. 2. This bond may be canceled by the Surety, as to future liability, by giving written notice by Certified Mail, addressed to the Principal at the address as stated in this bond, and to the Department of Labor and Industry, Construction Codes and Licensing Division, 443 Lafayette Road No., St. Paul, MN 55155-4341. Thirty (30) days after the mailing of that notice, this bond shall be null and void as to any liability thereafter arising, the Surety remaining liable, however, subject to all the terms, conditions, and provisions of this bond, for any and all acts covered by this bond up to the date of the cancellation.
Signed and sealed this day of

(SURETY SEAL)
Print Name of Principal (s) SIGNATURE OF PRINCIPAL(S)

Print Name of Principal (s)
Acknowledge (notarize) signatures on reverse side and attach power of attorney form. File with: Minnesota Department of Labor and Industry CCLD – Licensing and Certification 443 Lafayette Road N St. Paul, Minnesota 55155 LIC BD 05 (11/07)

SIGNATURE OF PRINCIPAL(S)

NAME OF SURETY

SIGNATURE OF ATTORNEY IN FACT (SURETY COMPANY)

A OR B AND C MUST BE COMPLETED
A. FOR ACKNOWLEDGEMENT OF Individual, Partnership, Limited Liability Company or Limited Liability Partnership (Note: If partnership all signatures required to be notarized. Please copy the page if necessary.) ) ) ss ) day of personally came

STATE OF COUNTY OF On this

to me well known to be the identical person(s) described in and who executed the foregoing bond and he/she/they acknowledged the same to be his/her/their own free act and deed.

(SEAL)

Notary Public, My Commission Expires

County,

B.

FOR ACKNOWLEDGEMENT of Corporate ) ) ss ) day of personally came

STATE OF COUNTY OF On this

who being by me duly sworn, did say that he/she is of ,a

corporation; and that said instrument was executed in behalf of the corporation by authority of its Board of Directors; that he/she acknowledged said instrument to be the free act and deed of the corporation.

(SEAL)

Notary Public, My Commission Expires

County,

PART C MUST BE COMPLETED BY THE SURETY COMPANY
C. FOR ACKNOWLEDGEMENT of Corporate Surety ) ) ss ) day of personally came to me personally known, who being by me duly sworn, did say that ,the STATE OF COUNTY OF On this and he/she is the attorney in fact, of

corporation whose name is affixed to the foregoing instrument; that the seal affixed to the foregoing instrument is the corporate seal of the said corporation; and that said instrument was executed in behalf of said corporation by authority of its board of directors and said acknowledged that he/she executed said instrument as attorney in fact as the free act and deed of said corporation.

(SEAL)

Notary Public, My Commission Expires

County,

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

Instructions for Filling Out Certificate of Insurance
Form must be completed by the insurance agent or insurance company, not by the business/contractor.
1. Select the insured’s license type from the available list and enter the insured’s license number. Note: New applicants will leave License No blank. 2. The insured name must be the legal name of the business entity as used on the business or contractor license application form and all other forms. The business/contractor name that an applicant uses to identify themselves must be filed or registered with Minnesota’s Office of the Secretary of State. Note: Only individual (sole proprietor) or partnership business types using their own true full name(s) of the individual or all partners as part of the business name are not required to be registered with the Office of the Secretary of State. Contact: 651-296-2803; 1-877-551-6767. 3. The DBA (doing business as) name is the assumed name for the insured entity, if different from the contractor’s or business’s legal name, as filed or registered with the Minnesota Office of the Secretary of State. 4. Physical street address for the licensed business entity (location from where the business is operated) and mailing address, if different from the physical street address. 5. Insurance policy information must include the “policy number,” dates of coverage, limits of coverage on policy, name of the insurance company, and the insurer’s NAIC ID number. 6. Name of person who certifies insurance coverage (name of agent, corporate officer, or other authorized representative), insurance agent’s license number, insurance agency’s name and address, insurance agency’s phone number. 7. Signature of the agent certifying the insurance coverage and the date certificate was signed.

Certificate of Insurance Laws (Excerpts)
Reprinted below are excerpts of the applicable laws requiring liability insurance for contractor/business licenses regulated by DLI. excerpted below are as enacted or changed by the 2007 Minnesota Legislature and their effective date. The laws

326.242, Subd. 6b (as amended) – Electrical Contractor, Elevator Contractor, Technology System Contractor Effective 12/01/2007 Each contractor shall have and maintain in effect general liability insurance, which includes premises and operations insurance and products and completed operations insurance, with limits of at least $100,000 per occurrence, $300,000 aggregate limit for bodily injury, and property damage insurance with limits of at least $50,000 or a policy with a single limit for bodily injury and property damage of $300,000 per occurrence and $300,000 aggregate limits. Such insurance shall be written by an insurer licensed to do business in the state of Minnesota and each contractor shall maintain on file with the commissioner a certificate evidencing such insurance which provides that such insurance shall not be canceled without the insurer first giving 15 days written notice to the commissioner of such cancellation. (Minn. Session Laws 2007, Chapter 140, Article 5, Section 20) 326.40, Subd. 2 (as amended) – Plumbing Business Effective 12/01/2007 …In addition, each applicant for a master plumber license or renewal thereof, shall provide evidence of public liability insurance, including products liability insurance with limits of at least $50,000 per person and $100,000 per occurrence and property damage insurance with limits of at least $10,000. The insurance shall be written by an insurer licensed to do business in the state of Minnesota and each licensed master plumber shall maintain on file with the commissioner a certificate evidencing the insurance providing that the insurance shall not be canceled without the insurer first giving 15 days written notice to the commissioner. The term of the insurance shall be concurrent with the term of the license. (Minn. Session Laws 2007, Chapter 140, Article 6, Section 8) 326.48, Subd. 4 (as amended) – High Pressure Piping Business Effective 12/01/2007 …each applicant for a high pressure pipefitting business license or renewal shall have in force public liability insurance, including products liability insurance, with limits of at least $100,000 per person and $300,000 per occurrence and property damage insurance with limits of at least $50,000. The insurance must be kept in force for the entire term of the high pressure pipefitting business license, and the license shall be suspended by the department if at any time the insurance is not in force. The insurance must be written by an insurer licensed to do business in the state and shall be in lieu of any other insurance required by any subdivision of government for high pressure pipefitting. Each person holding a high pressure pipefitting business license shall maintain on file with the department a certificate evidencing the insurance. Any purported cancellation of insurance shall not be effective without the insurer first giving 30 days' written notice to the department. (Minn. Session Laws 2007, Chapter 140, Article 10, Section 8) 326.601, Subd. 2 (b) (as amended) – Water Conditioning Contractor Effective 12/01/2007 The insurance shall provide coverage, including products liability coverage, for all damages in connection with licensed work for which the licensee is liable, with personal damage limits of at least $50,000 per person and $100,000 per occurrence and property damage insurance with limits of at least $10,000. The insurance shall be written by an insurer licensed to do business in this state and a certificate evidencing the insurance shall be filed with the commissioner. The insurance must remain in effect at all times while the application is pending and while the license is in effect. The insurance shall not be canceled without the insurer first giving 15 days' written notice to the commissioner. (Minn. Session Laws 2007, Chapter 140, Article 7, Section 5) 326.94, Subd. 2 (as amended) – Residential Building Contractor, Remodeler, Roofer, Manufactured Home Installer Effective 12/01/2007 Licensees must have public liability insurance with limits of at least $300,000 per occurrence, which must include at least $10,000 property damage coverage. The insurance must be written by an insurer licensed to do business in this state. The commissioner may increase the minimum amount of insurance required for any licensee or class of licensees if the commissioner considers it to be in the public interest and necessary to protect the interests of Minnesota consumers. (Minn. Session Laws 2007, Chapter 140, Article 8, Section 20) 327B.04, Subd. 4 (c) (2) (as amended) – Manufactured Home Manufacturer, Manufactured Home Dealer (subagency dealer) Effective 12/01/2007 …(2) a certificate of liability insurance in the amount of $1,000,000 that provides coverage for the agency and each subagency location. (Minn. Session Laws 2007, Chapter 140, Article 7, Section 5) This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD 651-297-4198. LIC-01 Instructions (11/07)

Form must be completed by the insurance agent or insurance company, not by the business/contractor.
PRINT IN INK or TYPE your responses. Unreadable or illegible certificates will be denied.

Certificate of Insurance
Covering General Liability and Property Damage
(This completed Certificate of Insurance must be submitted with an application form or renewal form. An ACORD form or any other Certificate of Insurance will not be accepted.)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road N St. Paul, MN 55155
LICENSE TYPE

Liability Insurance Coverage This is to certify that the insurance policy listed below has been issued to the named insured for the policy period indicated and that the policy meets the minimum coverage requirements applicable under Minnesota Statutes, section 327B.04, Subd. 4.

LICENSE NO (if applicable) POLICY NUMBER (pending is not acceptable)

Manufactured Home Dealer
INSURED (Business Name as registered with the Secretary of State) FROM (mm/dd/yyyy) TO (mm/dd/yyyy)

DOING BUSINESS AS (DBA) NAME (if different)

General Liability General Liability

Aggregate (Minimum)

Aggregate (Policy)

$1,000,000

STREET ADDRESS (no PO Box)

Policy provides liability insurance in the amount of $1,000,000.
CITY STATE ZIP CODE

MAILING ADDRESS (if different from above)

NAME OF INSURANCE COMPANY

CITY

STATE

ZIP CODE INSURANCE AGENT’S NAME (Print)

Data Practices Notice MN INSURANCE AGENT’S LICENSE NO. Minnesota law requires that contractors licensed by the Minnesota Department of Labor and Industry, Construction Codes and Licensing Division maintain on file with the Commissioner a certificate NAME OF INSURANCE AGENCY/CO. evidencing compliance with the liability insurance requirements prescribed in the applicable statute. Data provided on this form is used to determine compliance with the applicable Minnesota law and ADDRESS becomes public upon the issuance and/or renewal of the license. Cancellation Notwithstanding the expiration dates set forth in this certificate, should this policy be canceled or not renewed, the issuing company will provide 10 days advance written notice to the Certificate Holder of such cancellation or nonrenewal.

Resident Non-resident PHONE NUMBER

CITY

STATE

ZIP CODE

INSURANCE AGENT’S SIGNATURE

DATE

Licensing and Certification Services Phone: (651) 284-5080 E-mail: dli.license@state.mn.us Website: www.doli.state.mn.us TTY/MRS: (651) 297-4198 OFFICE USE ONLY Date of DLI Receipt

Certificate Holder Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road N St. Paul, MN 55155

LIC-01E (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5080

BCA FORM Bureau of Criminal Apprehension Criminal Background Check

PRINT IN INK or TYPE your responses THIS FORM MUST BE COMPLETED AND SIGNED BY ALL INDIVIDUAL APPLICANTS; IF THE LICENSE IS TO BE ISSUED TO A COMPANY, THIS FORM MUST BE COMPLETED AND SIGNED BY EACH OF THE COMPANY’S OWNERS, QUALIFYING PERSON, LIMITED OR GENERAL PARTNERS, CORPORATE OFFICERS, DIRECTORS, SHAREHOLDERS OWNING MORE THAN 10 PERCENT OF THE CORPORATION’S STOCK, L.L.C. OWNERS/GOVERNORS, MANAGERS OR EMPLOYEES WITH AUTHORITY TO EXERCISE MANAGEMENT OR POLICY CONTROL. THE DEPARTMENT OF LABOR AND INDUSTRY REQUIRES THIS INFORMATION TO CONDUCT CRIMINAL HISTORY CHECKS AND/OR VERIFY TAX IDENTIFICATION INFORMATION.

TO: RE:

Bureau of Criminal Apprehension and Minnesota Department of Revenue Request for criminal background check and request for disclosure/verification of tax identification number

PROVIDE PERSON’S COMPLETE LEGAL NAME LAST NAME (if legal list name is hyphenated, enter both names here)

FIRST NAME

MIDDLE NAME

ADDITIONAL MIDDLE NAME (if applicable)

MAIDEN NAME (if applicable)

FORMER LIST NAME or OTHER NAME (if applicable)

DATE OF BIRTH (mo/day/yr)

SOCIAL SECURITY NUMBER

TYPE OF LICENSE FOR WHICH YOU ARE APPLYING

THE FOLLOWING SECTION MUST BE COMPLETED IF THE LICENSE IS TO BE ISSUED TO A COMPANY NAME OF THE COMPANY

COMPANY’S ASSUMED NAME (if applicable)

COMPANY’S MINNESOTA TAX IDENTIFICATION NUMBER

YOUR TITLE OR POSITION IN THE COMPANY

CERTIFICATION AND AUTHORIZATION: • I, the undersigned, and my company have made application to the Minnesota Department of Labor and Industry for a regulated professional or occupational license. I certify that complete and accurate responses have been provided for all questions on the application. I hereby request and authorize the Bureau of Criminal Apprehension to conduct a background check of me through their records for licensing purposes. I hereby request and authorize the Minnesota Department of Revenue to disclose or verify the state tax identification number.
DATE

• •

SIGNATURE (mandatory)

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
LIC 10 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198

Information Regarding Salesperson List Form

This handout is prepared to assist in the understanding and use of the Salesperson List. A copy of the form is enclosed. Make photocopies of the BLANK Salesperson List form. Keep original BLANK form in your records for making future copies. The Salesperson List, is required to be submitted to the Commissioner by M.S. § 327B.07, Subd. 2 and Minnesota Rule Chapter 1350 Section 8200, and must be revised and submitted to the Construction Codes and Licensing Division within 10 days of hiring, firing, or otherwise changing the employment status of a salesperson. The Salesperson List is to be a running list showing all changes. If the dealer has several sheets of names, only a copy of the revised sheet(s) needs to be submitted. Each sheet should be identified with a page number. Please highlight or circle the change with a colored pen or highlighting pen. This will assist us in readily picking up the change in the salesperson status. It is important that you keep us informed with current salesperson information. M.S. § 327B.07, Subd. 2 “No salesperson shall work for more than one dealer during the same time period.” Keep the original list in your records of any salesperson change, sending a copy of the original, with the changes highlighted, to Construction Codes and Licensing Division within 10 days of change. All salespersons should be on one list only, not a separate list for each subagency location. Any person working for a dealer who is involved in selling of manufactured homes must be listed. This includes the licensee, partners, and corporate officers involved in sales. If you should have any questions on the procedures for the Salesperson List, please called our office at (651) 284-5849. The information you provide on this application will be used to determine if you meet the license requirements. Before a license is issued to you, M.S. § 270.72, subd 4, requires you to provide your social security number. The other information is required to process your application. Failure to provide the requested information may delay the processing of your application or may be grounds for denying your application. Under M.S. § 13.41, the information that you provide on this application, except for your name, and address is private data while the application is pending. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Once you are licensed, the information becomes public data and will be part of the agency’s permanent records.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

Instructions LIC MS 04 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198 LICENSE NO. NAME OF BUSINESS

Manufactured Home Dealer Salesperson List
Page of
BUSINESS PHONE

MD
LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH LAST NAME DATE OF BIRTH HOME ADDRESS HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME HOME ADDRESS FIRST NAME FIRST NAME MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN MIDDLE INITIAL CITY OR TOWN DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE EMPLOYED ZIP CODE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE DATE TERMINATED HOME PHONE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
LIC MS 04 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5080 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198 PRINT IN INK or TYPE

Certificate of Compliance Minnesota Workers’ Compensation Law

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 an activity 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 may result in a $1,000 penalty assessed against the applicant by the commissioner of the Department of Labor and Industry. A valid workers’ compensation policy will be kept in effect at all times by employers as required by law. YOUR LICENSE/BOND CERTIFICATE CANNOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION. You must complete number 1 or 2 below.
NUMBER 1 INSURANCE COMPANY NAME (not the insurance agent)

POLICY NO.

DATES OF COVERAGE to

OR NUMBER 2

I am not required to have workers’ compensation liability coverage because: I have no employees. I am self-insured (include permit to self-insure). I have no employees who are covered by the workers’ compensation law. (These include: spouse, parents, children and certain farm employees.) Other: _____________________________________________.
CONTRACTOR’S LICENSE NO (if applicable) BUSINESS TELEPHONE NO. FAX TELEPHONE NO.

BUSINESS NAME OF CONTRACTOR (Individual name only if no company name used)

DBA (doing business as name) (if applicable)

BUSINESS ADDRESS (PO Box must include street address)

CITY

STATE

ZIP CODE

COUNTY

E-MAIL ADDRESS

I certify that the information provided on this form is accurate and complete. APPLICANT SIGNATURE (mandatory) TITLE

DATE

NOTE: You must notify us if there is any changes to your Workers’ Compensation Insurance Information or Employee Status Change by resubmitting this form.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

LIC 04 (10/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198

Manufactured Home Dealer/Realtor Trust Account Information
PRINT IN INK or TYPE your responses.

A separate Trust Account Information form is required for each trust account.
LICENSED NAME OF BUSINESS

ADDRESS

LICENSE NO.

MDCITY STATE ZIP CODE TELEPHONE NUMBER

This certifies that the above named manufactured home dealer has a trust account at this bank as required by M.S. § 327B.08, subd. 3, 4, and 5.
NAME OF BANK

ADDRESS OF BANK

TRUST ACCOUNT NO.

CITY

STATE

ZIP CODE

DATE ACCOUNT OPENED

SIGNATURE OF BANK OFFICIAL

DATE

TITLE

TELEPHONE NUMBER

STATE COUNTY OF Sworn and subscribed before me

} } } ss.

Notary Public this day of County

(SEAL)

My commissioner expires

When complete, mail to Construction Codes and Licensing Division at the above address.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
LIC MS 05 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198 DEALER’S NAME DEALER’S ADDRESS

Manufactured Home Statement of Sale
(Tabulation is not Automatic)
PRINT IN INK or TYPE your responses.

MINNESOTA DEALER OR REAL ESTATE LICENSE NUMBER CITY STATE ZIP CODE

MAKE PRESENT LOCATION

DESCRIPTION OF MANUFACTURED HOME: MODEL MODEL YEAR SERIAL NUMBER SALE PRICE OF THE HOME $ TO THE SELLER PRICE PAID BY THE BUYER (sale price) $ % of the sale price) ) ) County (seller’s share, if any) USED

minus minus minus minus minus minus

Dealer’s commission (

First Mortgage Pay-Off (if any) (name of lender Second Mortgage Pay-Off (if any) (name of lender Personal Property Taxes paid to Charges, if any, for arranging financing for the sale (explain in detail) Any other charges to the seller (explain in detail)

AMOUNT DUE TO SELLER TO THE BUYER SALE PRICE OF THE HOME minus minus Earnest money payment made Down payment made AMOUNT DUE ON THE SALE FROM THE BUYER plus plus plus plus Personal Property Taxes paid to Charges, if any, for arranging financing for the sale (explain in detail) Title Fee (paid to the State) Payments, if any, made by the dealer on behalf of the buyer to Mobile Home Park. (Explain in detail the goods and services actually furnished by the mobile home part. Itemize the costs): NOTE: Minnesota law prohibits manufactured home parks from charging entrance or transfer fees. A violation of this law can result in a maximum civil penalty of $25,000. A park may not require a specific licensed manufactured home installer to install/set-up a manufactured home. If the manufactured home being sold is located in a manufactured home park, Minnesota law requires the dealer to disclose in writing to the buyer, the State law, M.S. § 327C.07 concerning the in park sale of manufactured homes prior to the buyer signing of the purchase agreement, (note homes manufactured after July 1, 1972, must comply to the manufactured home code when offered for sale or lease in Minnesota, see M.S. § 327.31-.35). Other charges to the buyer Explain: TOTAL AMOUNT DUE FROM BUYER County (buyer’s share, if any) (date) (date)

$

$

(If down payment is made in the form of property - not cash describe the property and state its value $

$ $

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. LIC MS 06 (11/07) 1 of 2

This statement of sale has been prepared as required by M.S. § 327B.08, subd. 1, and includes all charges, payments, sales commissions and other fees paid or payable in connection with this sale. I certify that SIGNATURE OF DEALER OR DEALER’S AGENT mobile home park has accepted the buyer as tenants. DATE

TYPE OR PRINT NAME

TITLE

I have read this statement and have received a copy. BUYER DATE

BUYER

DATE

SELLER

DATE

SELLER

DATE

THIS IS NOT TRUTH-IN-LENDING FORM The information you provide on this application will be used to determine if you meet the license requirements. Before a license is issued to you, M.S. § 270.72, subd 4, requires you to provide your social security number. The other information is required to process your application. Failure to provide the requested information may delay the processing of your application or may be grounds for denying your application. Under M.S. § 13.41, the information that you provide on this application, except for your name, and address is private data while the application is pending. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Once you are licensed, the information becomes public data and will be part of the agency’s permanent records.

2 of 2

STAPLE PHOTO OF BUSINESS LOCATION HERE

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufactured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5849 Fax: (651) 284-5743 www.doli.state.mn.us TTY: (651) 297-4198 PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

Manufactured Home Dealer Change of Address

EFFECTIVE DATE

The information provided on this form and any required attachments will be used to determine whether the applicant meets the license requirements. Failure to provide the requested information may delay the processing of the application or may be grounds for denying the application. Data provided on the application and attachments is public except for data provided on individuals, which under M.S. § 13.41 is private data (excluding name and mailing address) while the application is pending. Individuals are required to provide their social security numbers pursuant to M.S. § 270C.72, Subd. 4, before a license may be issued. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Individual’s applicant information becomes public data (except the individual’s social security number) and part of the agency’s permanent records once the license is issued. Instructions: Before a License for the new location can be issued, the “old” present license must be submitted with the completed change of address application. Also furnish the following: 1. Photo of new location. Staple or clear tape hinge photo within the dotted lines. If using space within a commercial building, provide a floor plan. This may be a rough sketch to verify compliance with Minn. Rule 1350.7200, subp. 2. 2. Photocopy of warranty deed, contract for deed or one year minimum lease for the real estate and, in addition, proof of ownership of a manufactured home if used as the office. Proof of ownership is a copy of Title listing the dealership as owner. 3. Enter the actual or proposed effective date in the box provided – upper right hand corner. 4. Submit license fee check for $10.00 payable to: Minnesota Department of Labor and Industry I will be: (check applicable box or boxes) Brokering or Listing Used Manufactured Homes Selling New Manufactured Homes Selling Used Manufactured Homes

USE OF ANY BUSINESS NAME OTHER THAN GIVEN, REQUIRES A SEPARATE LICENSE. I state that the following established place of business is located in an area where zoning regulations allow commercial activity.
VERIFIED BY (name of local zoning administrator) DATE

Check applicable box:

I own this location

I have a one year minimum lease

APPLICANT’S NAME (must be owner, partner or corporate president)

NAME OF BUSINESS TO BE LICENSED

MAIN OFFICE BUSINESS ADDRESS (number and street)

PHONE NO.

CITY

STATE

ZIP CODE

COUNTY

NAME OF MANAGER

MANAGER’S HOME PHONE NO.

MANAGER’S HOME ADDRESS

CITY

STATE

ZIP CODE

Office Use Only DATE RECEIVED

DATE ISSUED

PAID CHECK NO.

LICENSE NO.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. LlC MS 07 (11/07)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing / Manufatured Structures 443 Lafayette Road North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198

Manufactured Home Dealers Display/Storage Reporting Form

DEALER’S NAME

PRINT IN INK or TYPE your responses LICENSE NO.

MDADDRESS CITY STATE ZIP CODE

Home to be:

Stored

Displayed

EVENT NAME (if displayed)

LOCATION/ADDRESS

CITY

STATE

ZIP CODE

FROM (month/day/year)

TO (month/day/year)

Indicate the dates the homes will be displayed/stored:

The following information is not required, but any voluntary information provided would be for Construction Codes and Licensing Division use only. Yes Yes No — Local authority having jurisdiction notified? No — Were special permits required by authority having jurisdiction?

TYPE OF SPECIAL PERMIT REQUIRED

COST OF SPECIAL PERMIT

The information provided on this form and any required attachments will be used to determine whether the applicant meets the license requirements. Failure to provide the requested information may delay the processing of the application or may be grounds for denying the application. Data provided on the application and attachments is public except for data provided on individuals, which under M.S. § 13.41 is private data (excluding name and mailing address) while the application is pending. Individuals are required to provide their social security numbers pursuant to M.S. § 270C.72, Subd. 4, before a license may be issued. Disclosure of this information to others may occur as authorized or required by law, including the Attorney General’s Office, the Department of Revenue, the Department of Human Services, and/or for the purpose of verification and investigation. Individual’s applicant information becomes public data (except the individual’s social security number) and part of the agency’s permanent records once the license is issued. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

LIC MS 08 (11/07)