Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443

Lafayette Road N St. Paul, MN 55155 Phone: (651) 284-5067 Fax: (651) 284-5748 E-mail: dli.license@state.mn.us Website: www.doli.state.mn.us TTY/MRS: (651) 297-4198

For DLI Office Use Only Application Deadline Date

Reset
Billing Code

12/31/2007
Restricted License Application Fee

4832
Amount Paid

$30.00
Method of Payment Cash Check Money Order Date Paid (Deposit Date) Check / MO #

The $30 application fee is payable to Department of Labor and Industry, must accompany the application and be mailed to: Minnesota Department of Labor and Industry Financial Services/Plumbing 443 Lafayette Road N St. Paul, MN 55155 By law applicants without at least 2-years documented practical plumbing experience will be denied.

Application Number

Date Recorded

Decision

Decision Date Recorded

Approve

Deny
Reason Denied

Checks returned for nonpayment will be charged a $30 fee (Minn. Stat. § 604.113, subd. 2)

Application for Restricted Plumber License
Plumbing License Required Statewide. The 2007 Minnesota Legislature extended statewide, effective December 1, 2007, the requirement that throughout the state all persons (with few exceptions) working at the business of plumbing must be licensed plumbers or registered plumbing apprentices. A special class of restricted plumbing licenses was created by the Legislature that limits holders to working in cities with a population of 5,000 or less, which is available to previously unlicensed individuals with two or more years of documented practical plumbing experience. Persons having certification as pipelayers may perform some plumbing installation outside of buildings without a license, if properly bonded.
PRINT IN INK or TYPE your responses.
Unreadable or illegible applications will be denied. Incomplete applications will not be processed and will returned to sender.

Mark the box of the license you are applying to receive.
Document your practical plumbing experience for the license on the back of this application form.

Restricted Journeyman Plumber License Must have at least 2-Years practical plumbing experience. Engage in plumbing trade in all areas of state except cities and towns with a population of more than 5,000. License must be renewed annually at Journeyman fee ($55). If contracting to do plumbing work, must have $25,000 bond filed with DLI and have required liability insurance coverage. Items with * are required to process your application. LAST NAME* FIRST NAME*

Restricted Master Plumber License Must have at least 4-Years practical plumbing experience. Engage in plumbing trade in all areas of state except cities and towns with a population of more than 5,000. License must be renewed annually at Master fee ($120). If contracting to do plumbing work, must have $25,000 bond filed with DLI and have required liability insurance coverage.

MIDDLE INITIAL

ADDRESS*

CITY

STATE

ZIP CODE*

HOME PHONE NUMBER

WORK PHONE NUMBER

DATE OF BIRTH DATE (mm/dd/yyyy)*

SOCIAL SECURITY NUMBER*

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, Minn. Stat. § 270.72, subd. 4, requires you to provide your social security number. The other information is required to process your application. Failure to provide requested information may delay the processing of your application or may be grounds for denying your application. Under Minn. Stat. § 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 (except for your social security number) 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. PLB 02 (8/07)

Application for Restricted Plumber License Documentation of Practical Plumbing Work Experience
Applicants for restricted master and journeyman plumber licenses must provide documentation of their practical plumbing work experience earned prior to making application to qualify for a restricted license. DLI’s plumbing bond and plumber’s apprentice records will be used, as necessary, to validate claims of practical pluming experience. Restricted Master Plumber: Restricted Journeyman Plumber: Applicant must show four (4) years practical plumbing experience. Applicant must show two (2) years practical plumbing experience.

Applicants with four (4) years documented practical plumbing experience may apply for the Restricted Journeyman Plumber license and are not required to apply for the Restricted Master Plumber license. Applicants must, however, choose a restricted license and submit the completed application by December 31, 2007. Qualification: Contracting for Plumbing Work Practical plumbing experience claimed as “contracting for plumbing work” will only qualify for those years that were covered by a $25,000 plumbing code compliance bond properly filed with the State of Minnesota pursuant to Minn. Stat. § 326.40. I filed a plumbing bond pursuant to Minn. Stat. § 326.40 in the following years while owning or working for the identified plumbing business (es). I claim those years contracting for plumbing work and ask that DLI verify my bond filings.
Calendar Year Plumbing Company Name Bond number Date Bond Filed

Qualification: Practical Plumbing Experience as Registered Plumber’s Apprentice Practical plumbing experience claimed for work in Minnesota since July 1, 1987, which is not qualified as “contracting for plumbing work,” will only qualify for those years the applicant was properly registered as a Plumber’s Apprentice. I am or have been registered as a Plumber’s Apprentice with the State of Minnesota and claim the hours reported annually for the following registration number.

PA

I am or have been registered as a Plumber’s Apprentice in a voluntary Joint Plumbers Apprenticeship Program and claim the recorded hours worked and have attached written verification from the joint apprenticeship program. Qualification: Practical Plumbing Experience – Pre 07/01/1987 in Minnesota and Out-of-State Practical plumbing experience claimed for work in Minnesota before July 1, 1987 and outside the state of Minnesota shall be verified by affidavit. I claim practical plumbing experience for plumbing work performed in Minnesota before July 1, 1987 equal to ( years / four years (select one)) as demonstrated on the attached verification and affidavit form(s). I claim practical plumbing experience for plumbing work performed outside the state of Minnesota equal to ( four years (select one)) as demonstrated on the attached verification and affidavit form(s). two

two years /

Certification I certify all of the information submitted in this application and any attachments are true and complete, that this license prohibits me from performing plumbing work in cities and towns with populations exceeding 5,000 according to the most recent U.S. Census, and that by becoming a Restricted Master Plumber the annual license fee will equal the Master Plumber license fee ($120) and that by becoming a Restricted Journeyman Plumber the annual license fee will equal the Journeyman Plumber license fee ($55).
PRINT NAME SIGNATURE OF APPLICANT DATE

Minnesota Department of Labor and Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road N St. Paul, MN 55155 Phone: (651) 284-5067 E-mail: dli.license@state.mn.us Website: www.doli.state.mn.us TTY/MRS: (651) 297-4198 APPLICANT NAME LAST NAME PRACTICAL PLUMBING WORK EXPERIENCE COMPANY NAME ADDRESS CITY TELEPHONE NO. POSITION MAJOR WORK ACTIVITIES 1. 2. 3. 4. 5.

Affidavit of Practical Plumbing Work Experience Restricted Plumber License
PRINT IN INK or TYPE your responses.

FIRST NAME

DATE EMPLOYMENT DATES FROM TO

STATE FAX NO. SUPERVISOR

ZIP CODE

NOTICE: Knowingly providing inaccurate or fraudulent information to the department or failure to comply with a reasonable request for information, may constitute a violation of the Health Enforcement Consolidation Act of 1993, and may be subject to a fine of up to $10,000 (Minn. Stat. § 144.989 to 144.993). NOTICE: Under Minn. Stat. § 13.41, information you provide on this application is private data 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. The applicant, whose name is (PRINT) 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. Subscribed and sworn to before me Signature of Applicant this Notary Public (SEAL) My Commission expires
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.

day of

PLB 01 (8/07)