Minnesota Department of Labor and Industry Financial Services/HPP 443 Lafayette Road North St.

Paul, MN 55155

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APPLICATION FOR CONTRACTOR PIPEFITTER BUSINESS LICENSE
Please PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied. Please submit completed application and appropriate fee to the above address.

BUSINESS NAME ADDRESS CITY AREA CODE AND PHONE NUMBER CONTRACTOR LICENSE HOLDER NAME #1 CONTRACTOR LICENSE HOLDER NAME #2 CONTRACTOR LICENSE HOLDER NAME #3 SIGNATURE SIGNATURE SIGNATURE STATE

BUSINESS LICENSE #

ZIP CODE AREA CODE AND FAX NUMBER LICENSE NUMBER LICENSE NUMBER LICENSE NUMBER

WORKERS’ COMPENSATION INSURANCE Workers’ Compensation Insurance Workers’ Compensation Insurance Policy Workers’ Compensation Insurance Company Number Expiration Date I am self-employed and have no employees Exempt (check here) No Workers’ Compensation insurance information is provided because: I employ only family members BOND/LIABILITY INSURANCE Liability Insurance Company Liability Insurance Policy Number Liability Insurance Expiration Date Bond Company Name Bond Number Bond Expiration Date

I have not enclosed a copy of the bond, or insurance certificate because I work only on property owned or leased by my employer. $15,000 Contracting Pipefitter Bond. Original enclosed. $450.00 Business License fee enclosed. (Make checks payable to Department of Labor and Industry.) Must be renewed by January 31 of each year. I VERIFY THAT ALL INFORMATION IS CORRECT. SIGNATURE OF LICENSE HOLDER Exempt (check here)
The information you provide on this application will be used to determine if you meet the license requirements. The requested 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 provided in different forms, such as large print, Braille or audiotape, if you call (651) 284-5080 or (651) 297-4198/TTY.

Office Use Only

Approve

Deny ILL NOS CIP LIA = = = =

Inspectors Initials ILLEGIBLE OR UNREADABLE WOR = NO SIGNATURE ON APPLICATION COMPLETED IN PENCIL INSUFFICIENT LIABILITY INFORMATION Application Number Purchase Order No (state agencies only) INSUFFICIENT WORKERS COMPENSATION INFORMATION

REASON(S) DENIED: WRS = WRONG SIGNATURE NOA = NO APPLICATION SUBMITTED NOF = NO FEE SUBMITTED BON = INSUFFICIENT BOND INFORMATION Office Use Only Date Paid Business License Fee Check Number Money Order Number

Business Licence Number Interagency Payment

CAIS HPP-05.WP (7/07)

Bond No. CONTRACTING HIGH PRESSURE PIPING BOND

KNOW ALL MEN BY THESE PRESENTS, That principle, and are held and firmly bound unto the State of Minnesota in the amount of as sure

as

FIFTEEN THOUSAND DOLLARS
For the payment of this, well and truly to be made, we bind ourselves, our representatives and successors, jointly and severally, firmly by these presents. Sealed with our seals and dated this day of , 20

The condition of this obligation is such that whereas the principal has applied for a license to engage in the business of a Contracting Steamfitter in accordance with the requirements of M.S. 326.46-326.52 at:

STREET ADDRESS

CITY

STATE

ZIP CODE

NOW THEREFORE, If such license shall be granted and if the principal shall conform to and not violate any of the terms or requirements of said legislative act or any contract made by him in the course of the conduct of the business so licensed, and shall faithfully and lawfully perform all work entered into by him within the State of Minnesota, then this obligation shall be void; otherwise to be and remain in full force and effect.

This bond shall be effective and run concurrently with the period of the aforesaid license from the date said license is granted in the current year and shall expire on December 31, 20 .

It is hereby declared, in accordance with the statute, that action on this bond may be brought and prosecuted in the name of any person damaged by any breach of the conditions thereof, and that successive actions may be maintained thereon. (CORPORATE SEAL) PRINCIPAL

PRINCIPAL

SURETY

SURETY

BY ATTORNEY IN FACT

CAIS HPP-22.WP (8/04)

STATE OF MINNESOTA COUNTY OF On this day of

ACKNOWLEDGMENT BY INDIVIDUAL PRINCIPAL } } } , 20 before me personally appeared ss.

, to me known to be the person(s) described in and who executed the foregoing instrument, and acknowledged that he executed the same as free act and deed

(Notarial Seal) Notary Public My commission expires (The corporate surety will attach the usual slip acknowledgement and a power of attorney granting to the attorney in fact, authority to sign on behalf of the corporate surety.) ACKNOWLEDGMENT BY CORPORATE PRINCIPAL } } COUNTY OF On this day of } , 20 and to me personally known, who, being by me duly sworn; did say that they are the and the respectively; of the corporate principal named in the foregoing bond; that before me personally appeared ss. County, MN

STATE OF MINNESOTA

seal affixed thereto is the corporate seal of the corporation that said bond was executed in behalf of the corporation by authority of its board of directors, and they acknowledge that said instrument to be the free act and deed of the corporation.

(Notarial Seal) Notary Public My commission expires Contracting Highpressure Piping Bond Bond No. To the State of Minnesota Recorded By: Department of Labor and Industry, Code Administration and Inspection Services Filed: ,20 ,20 County, MN

SECRETARY OF STATE

CONTINUATION BOND FORM (to be attached to original bond form)
BOND NUMBER STREET ADDRESS CITY STATE NAME OF CONTRACTING PIPEFITTER PHONE ZIP CODE

ORIGINAL DATE BOND ISSUED Statutes 325.48, Subpart 2. NAME OF BONDING COMPANY STREET ADDRESS CITY NAME OF CONTRACTING COMPANY STREET ADDRESS CITY STATE STATE

20

in the amount of $15,000 as stated in Minnesota

PHONE ZIP CODE

PHONE ZIP CODE

The bond described above, and to which this certificate is attached, is hereby continued in force from the date of last renewal for an extended term ending the 31st day of December, 20 .

Dated this

day of

, 20

PRINCIPAL PRINCIPAL SURETY COMPANY BY

CAIS HPP-21.WP (8/04)