Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St.

Paul, MN 55155 (651) 284-5065

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Certificate of Exemption Application
Minnesota Statutes § 326.83

PRINT IN INK or TYPE your responses This application must be completed by any residential building contractor, residential remodeler or residential roofer who claims an exemption from licensure pursuant to Minnesota Statutes §326.84, subd. 3(5), because they do not expect to exceed $15,000 in gross annual receipts derived from their contracting, remodeling or roofer activities during this calendar year. Please read the application carefully and complete all information requested. Incomplete applications will be returned. The application must be completed and signed by an owner, partner or corporate officer. There is no fee to apply for this Certificate of Exemption. Please return the completed application to the Minnesota Department of Labor and Industry at the address above. Keep a copy of the application for your records. You may be required to show your exemption card to obtain a municipal building permit. If you have any questions, please contact the Department of Labor and Industry, Construction Codes and Licensing Division, Licensing and Certification Services at the number above. TYPE OF EXEMPTION APPLICATION Residential building contractor APPLICANT INFORMATION APPLICANT IS: BUSINESS NAME DBA (If DBA name is different from legal name listed above, attached a Certificate of Assumed Name filed and stamped by the Minnesota Secretary of State) CORPORATE NAME (if applicable) BUSINESS ADDRESS (PO Box must include RR# or street address) CITY STATE ZIP CODE Individual proprietorship Remodeler Roofer BUSINESS PHONE NUMBER

Corporation

Partnership

OWNER INFORMATION List name(s), address(es), date(s) of birth and social security number(s) of all owner(s). Attach additional pages if needed. OWNER FULL NAME DATE OF BIRTH SOCIAL SECURITY NUMBER OWNER STREET ADDRESS OWNER FULL NAME OWNER STREET ADDRESS OWNER FULL NAME OWNER STREET ADDRESS OWNER FULL NAME OWNER STREET ADDRESS OWNER FULL NAME OWNER STREET ADDRESS CITY DATE OF BIRTH CITY DATE OF BIRTH CITY DATE OF BIRTH CITY DATE OF BIRTH CITY STATE ZIP CODE

SOCIAL SECURITY NUMBER STATE ZIP CODE

SOCIAL SECURITY NUMBER STATE ZIP CODE

SOCIAL SECURITY NUMBER STATE ZIP CODE

SOCIAL SECURITY NUMBER 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.
Office Use Only PROCESSING DATE CERTIFICATE OF EXEMPTION NUMBER

RBC 19 (12/06)

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I, the above named applicant, hereby certify that I am owner, partner or corporate officer of the above named company and that I do not expect the company to exceed $15,000 in gross annual receipts derived from residential building contracting, residential remodeler or residential roofer activities during this calendar year. Therefore, it is my belief that the company qualifies for an exemption from licensure. I understand that “gross annual receipts” are defined as the total amount derived by the company from residential building contractor, residential remodeler or residential roofer activities, regardless of where the activities are performed, and may not be reduced by cost of goods sold, expenses, losses or any other amount. I understand that I must renew the Certificate of Exemption each year and that this certificate expires March 31 of each year. I understand that if I exceed $15,000 in gross receipts, regardless of where the activities are performed, during any calendar year, that I must immediately surrender the Certificate of Exemption and apply for the appropriate license. I understand that if I am exempt from the licensure requirements, I may be required by a municipality to obtain a local license prior to becoming eligible to obtain a building permit. I understand that a Certificate of Exemption is not a license and that I am prohibited from advertising as a licensed contractor unless I or my company holds a municipal license. I understand that I am required and may be requested to provide the Department of Labor and Industry with additional information to verify qualification for this exemption. I HEREBY CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT ALL OF THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE.

All applicants must answer the following questions. If the answer to any question is “yes”, attach a detailed explanation and all legal documentation, if application.
Have you (applicant) or the applicant’s qualifying person, owners, partners, officers, directors, shareholders owning more than 10 percent of the corporation’s stock, LLC owners/governors, managers or employees exercising management or policy control, ever: 1. Held a residential building contractor, remodeler, roofer, manufactured home installer or any other occupational, professional license in any state including Minnesota? If yes, new applicants must provide a verification of licensure certified by the state(s). Been the subject of any inquiry or investigation by any division of the Minnesota Department of Commerce or Minnesota Department of Labor and Industry? Had any occupational, professional or vocational license or permit censured, suspended, revoked, canceled, terminated or been the subject of any type of administrative action in Minnesota or any other state? Been charged with, convicted of, indicated for, or entered a plea to, any criminal offense (felony, gross misdemeanor or misdemeanor), other than traffic violations, in any state or federal court within the last 10 years? Been a defendant in any lawsuit or been named in a civil judgment, involving claims of fraud, misrepresentation, conversion, mismanagement of funds, breach of fiduciary duty or breach of contract? Been notified by the commissioner of the Department of Revenue, pursuant to Minnesota Statutes, Section 270.72, that you currently owe the State of Minnesota any delinquent taxes? Exercised management or policy control over, or owned 10 percent or more of the stock of any company that has failed in business or filed a bankruptcy petition or been declared bankrupt? Been the subject of any outstanding unsatisfied judgment(s) relating to any residential contracting or residential remodeling, residential roofing or manufactured home installer activities? Has the applicant’s business entity undergone a change in name, ownership or control, or has there been a sale or transfer of the applicant’s business entity in the past five years? If yes, attach a list of the names and addresses of all prior, predecessor, subsidiary, affiliated, parent or related entities, and whether each such entity or its owner, officers, directors, members or shareholders hold more than 10 percent of the stock would have answered “yes” to questions 1 through 8. Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

2. 3. 4. 5. 6. 7. 8. 9.

Yes

No

10. Have any unclaimed property (unclaimed funds or property more than three years old) to report under Minnesota Statutes, section 345.37? 11. Have you (applicant) or the applicant’s qualifying person, owners, partners, officers, directors, employees exercising management or policy control, managers, limited liability company owners/governors or shareholders owning more than 10 percent of the stock in the corporation ever been affiliated with any residential contracting or residential remodeling, residential roofing or manufactured home installer business entity that engaged in any activity that would result in a “yes” answer to the above questions 1 through 8?

Yes

No

Yes

No

I certify that this document has not been changed in any manner from the form adopted by the Department of Labor and Industry. SIGNATURE OF OWNER PARTNER OR CORPORATE OFFICER DATE

PRINT THE ABOVE SIGNATURE

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Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5065

Certificate of Exemption Checklist

Failure to include all requested information will result in your application being returned to you. Complete the Bureau of Criminal Apprehension Criminal Background Check form and submit with the complete application. Enclose the Assumed Name Certificate, if applicable, and be sure the name on the application is identical to the Assumed Name Certificate. Attach a written, detailed explanation for any questions answered “yes” on the application. Sign and date the application. Mail all documents to address above. License will be mailed to business address after application processing. Note: Application processing is not currently available at the DLI public service counter. Note: Secretary of State business filing and Assumed Name Certificate application information is available via telephone (651) 296-2803, or online at www.sos.state.mn.us.

CORPORATIONS A copy of your Articles of Incorporation or Certificate of Incorporation. Both of these documents must have the Secretary of State’s file number on them. A list of the names and addresses of all corporate officers, directors and shareholders owning more than 10 percent of the outstanding stock in the corporation. Assumed Name Certificate if the DBA is different from the corporate name.

PARTNERSHIPS A partnership agreement that lists the names and addresses of each partner, amount of ownership and signed by each partner. ASSUMED NAME FILING INFOMATION Any individual, corporation, partnership or limited partnership that is doing business in the state of Minnesota under a name other than the full name (first and last) of each person involved in the business, or the legal corporate or partnership name, must file an assumed name. Examples: "John Smith Construction" would not be required to file if John Smith is the owner of the business. However, "Smith's Construction" would be required to file because it does not contain the full first and last name of the owner. Similarly, the legally incorporated company "ABC Construction" does not need to file an assumed name, because that is its legal corporate name. If an entity does business under any name other than the legal corporate name, an assumed name filing would be required. The reason for filing an assumed name is not to protect the name against use by other persons, but to provide information to the consumer about the identity of the business owner. Applications for assumed name filings may be obtained from the Secretary of State, online at www.sos.state.mn.us, by mail at 180 State Office Building, St. Paul, MN 55155, or by telephone at (651) 296-2803. Instructions for filing an assumed name are provided on the application 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.

RBC 20 (12/06)