Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing Unit 443 Lafayette Road

N., St. Paul, MN 55155-4342 Phone: (651) 284-5067 Fax: (651) 284-5748 www.doli.state.mn.us TTY/MRS: (651) 297-4198

Master Plumber and Journeyman Plumber Reciprocity Application

Plumbers licensed in North Dakota or South Dakota, who wish to become licensed in the state of Minnesota by reciprocal agreement, must contact their state plumbing board to receive a Certificate of State Endorsement. The reciprocity agreements with the states of North Dakota and South Dakota apply to nonresident (not a resident of Minnesota) licensed plumbers.

The attached application must be completed in its entirety and returned in the enclosed envelope with the following: 1. A copy of your current license. 2. A Certificate of State Endorsement completed by your state licensing agency. 3. The appropriate fee of $55 for the journeyman plumber license, or $120 for the master plumber license. Checks returned for nonpayment will be charged a $30 fee (M.S. § 604.113, subd. 2). 4. If you are applying for the master plumber license, you must complete the attached Certificate of Compliance Minnesota Workers’ Compensation Law form. If you are applying for the journeyman plumber license, you do not need to complete this form. 5. You must have passed an examination for licensure in either North Dakota or South Dakota that is equivalent to the licensure you are applying for in Minnesota. Please note that all applications submitted to this office with a Minnesota address will be denied and returned. Reciprocity applies only to nonresidents. If you have any questions, please contact us at (651) 284-5067.

Bonding Requirement
Any person who contracts to do plumbing work within the state of Minnesota, regardless of population of city or town, whether a licensed plumber or not, must provide evidence of a $25,000 plumbing code compliance bond to the commissioner of the Department of Labor and Industry, or provide evidence of this bond to the local jurisdiction where the work is to be performed, if the local jurisdiction has an ordinance requiring such bonding. To request a bond form, please call (651) 284-5067. If you have any questions, please contact the unit supervisor at (651) 284-5889. 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.

PPR-25 (5/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing Unit 443 Lafayette Road N., St. Paul, MN 55155-4342 Phone: (651) 284-5067 Fax: (651) 284-5748 www.doli.state.mn.us TTY/MRS: (651) 297-4198

Reset

Application for Journeyman/Master Plumber Reciprocity

PRINT IN INK or TYPE your responses. PLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION. Application must be typewritten or printed in ink. Answer all questions in full. Incomplete applications will not be processed; they will be returned to submitter. The application must be accompanied by appropriate fee, payable to the Department of Labor and Industry. Mail payment to: Department of Labor and Industry, Financial Services, 443 Lafayette Road N., St. Paul, MN 55155. Checks returned for nonpayment will be charged a $30 fee (M.S. 604.113, subd. 2.) Designate the type of license for which you are applying by putting an “X” in the appropriate square. $55 Journeyman Plumber Reciprocity License (4828) $120 Master Plumber Reciprocity License (4832)
LAST NAME FIRST NAME MIDDLE NAME

ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE NO.

WORK PHONE NO.

DATE OF BIRTH (mm/dd/yyyy)

SOCIAL SECURITY NO.

Are you self-employed in practical plumbing installation?
FIRM’S NAME

No

Yes
PHONE NO.

If yes, give your firm’s name and address.

ADDRESS

CITY

STATE

ZIP CODE

Are you licensed in another state? ACCOMPANY this application.

No

Yes

If yes, a copy of your current license or other evidence MUST

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 1-800342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

FOR OFFICE USE ONLY
FEE DEPOSIT DATE DEPOSIT NO.

Denied Approved

LICENSE NO.

PPR-26 (5/06)

LIST EDUCATION RELATED TO LICENSE FOR WHICH YOU ARE APPLYING

Page 2
PRINT IN INK or TYPE your responses

High School, College, University, Technical or Vocational School Name Location

Dates of Attendance From To

Certificate or Degree (Received (AA, BS, etc.)

Title of Program or Subjects Taken (major/minor)

LIST EXPERIENCE RELATED TO LICENSE OR REGISTRATION FOR WHICH ARE YOU APPLYING:
Organization Position Major Activities: 1. 2. 3. 4. Organization Position Major Activities: 1. 2. 3. 4. Organization Position Major Activities: 1. 2. 3. 4. Location Supervisor % of time Length of Experience From Mo./Yr. To Mo./Yr.

Full Time Part Time

Location Supervisor % of time

Length of Experience From Mo./Yr. To Mo./Yr.

Full Time Part Time

Location Supervisor % of time

Length of Experience From Mo./Yr. To Mo./Yr.

Full Time Part Time

ATTACHED ADDITIONAL SHEETS IF NECESSARY. BE SURE TO INCLUDE ALL INFORMATION REQUESTED ABOVE.

ATTACH ADDITIONAL SHEETS, IF NECESSARY. BE SURE TO INCLUDE ALL INFORMATION REQUESTED ABOVE. Knowingly providing inaccurate or fraudulent information to the Department or failure to comply with a reasonable request for information, may constitute a violation of M.S. § 144.989 to 144.993 and may be subject to a fine of up to $10,000. Under M.S. § 13.41, information you provide on this application is private date until the time you are licensed. Once you are licensed, the information becomes public data and will be part of the agency’s permanent file.
PPR-26 (5/06)

RECIPROCITY APPLICATION continued

Page 3

The person, whose name is being sworn, declares that the foregoing statements subscribed to by him/her are true to the best of his/her knowledge and belief, and that he/she personally signed this application. Signature of Applicant

Subscribed and sworn before me on this of Signature of Notary ,

day

(SEAL)

PPR-26 (5/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing Unit 443 Lafayette Road N., St. Paul, MN 55155-4342 Phone: (651) 284-5067 Fax: (651) 284-5748 www.doli.state.mn.us TTY/MRS: (651) 297-4198

Certification of Compliance Minnesota Workers’ Compensation Law
(Master Plumbers Only)

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 or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers’ compensation insurance coverage requirement of M.S. 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 CANNOT BE ISSUED WITHOUT THE FOLLOWING INFORMATION:
INSURANCE COMPANY NAME (NOT the insurance agent)

POLICY NUMBER

DATES OF COVERAGE (from/to)

OR
I am not required to have workers’ compensation liability coverage because: I am an employee of a master plumber. 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. Other:

I certify that the information provided on this form is accurate and complete.
APPLICANT’S SIGNATURE DATE

DOING BUSINESS AS (business name if different than your name)

BUSINESS 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 1-800342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.

PPR-27 (5/06)