Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St.

Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied. CURRENT CONTRACTOR LICENSE NUMBER

Reset

Application for Technology System Contractor License
For the period August 1, 2006 through July 31, 2008
(Except for social security numbers, all information on contractor license application forms is public)

LICENSE FEE Renewal fee: $200 Late fee: $100 if not renewed 30 days after expiration Prorated license fee schedule for a new license New licenses issued: 08/01/06 thru 07/31/07 $200 New licensed issued: 08/01/07 thru 07/31/08 $100 Make check payable to: Department of Labor and Industry Submitting an application and depositing the fee does not constitute being licensed. The Department will not renew a license until all the applicable requirements have been met. BUSINESS TELEPHONE NUMBER
An answering service is not acceptable

FORMER NAME

FORMER ADDRESS

CITY

STATE

ZIP CODE

1. BUSINESS NAME OF CONTRACTOR
Individual name only if no company name used - See instructions

2. BUSINESS ADDRESS 3. MAILING ADDRESS (if different from above)

CITY

STATE

ZIP CODE

COUNTY

CITY

STATE

ZIP CODE

COUNTY

4. BUSINESS TYPE
(check only one)

Individual (sole proprietor) Partnership Corporation Foreign Corporation

Limited Liability Company Limited Liability Partnership Other

State business is organized in:

All partners of a partnership and limited liability partnership must sign this application form and the contractor's bond, and their names must appear on the Certificate of Insurance form and the contractor's bond. Except when an individual or partnership is doing business under their own true name(s) all businesses must be registered with the Office of Secretary of State, 180 State Office Building, St. Paul, MN 55155, (651) 296-2803. 5. LIST OWNER, ALL PARTNERS, ALL OFFICERS, OR ALL LIMITED LIABILITY COMPANY MEMBERS All requested information must be provided. (Attach additional list if necessary)
Last Name First MI Title Resident Address City State ZIP Code

6. If technology system business is conducted at locations other than the address shown under #2 or #3, list address and phone number below. Out of state businesses, except states contiguous with Minnesota, must provide their Minnesota place of business and telephone number.
STREET ADDRESS CITY STATE ZIP CODE PHONE NUMBER (area code)

THE SECOND PAGE MUST BE COMPLETED SPACE BELOW RESERVED FOR OFFICE USE
Check # Application Cert. Employ. Contractor’s License # OK’d by TSC 01 (8/07) Effective Date Bond SOS Fee Liability Ins. PL Technician # Late Fee Tax Form (STAMP)

7. This is to certify that I am or have in my employ a licensed power limited technician who will be actively responsible for the performance of all technology system work, including planning, laying out and supervising installation of all such work, in accordance with the requirements of M.S. §§ 326.01 and 326.241-248 and Minn. Rules Chapter 3800.
PRINT NAME OF RESPONSIBLE POWER LIMITED TECHNICIAN LICENSE HOLDER ADDRESS POWER LIMITED TECHNICIAN LICENSE NUMBER

EXPIRATION DATE

CITY

STATE

ZIP CODE Note: The responsible power limited technicians license must be current in order for the contractor license to be valid.

8. Do you have employees? Yes No (The responsible power limited technician listed under #7 is an employee unless s/he is the owner, an officer, member, or partner) See the application instructions If the company has employees that are excluded under M.S. § 176.041. If yes, the following information must be completed: a. Workers’ Compensation Insurance Policy Number: Name of Insurance Company: b. State Unemployment Insurance Account Number: 9. The following information must be provided unless the applicant is an individual (sole proprietor) or one-member limited liability company and does not have employees or taxable sales: a. Federal Employer Identification Number (FEIN): b. Minnesota Identification Number (MN ID):
See the application instructions if the company is from outside of Minnesota and is not required to withhold Minnesota income taxes.

10. NAME OF BONDING COMPANY ($5,000 performance bond attached)

11. NAME OF INSURANCE COMPANY (Certificate of Insurance showing evidence of general liability insurance in the amounts required under M.S. § 326.242, subd. 6(b) attached)

12. This is to certify that the company making this application is in compliance with the provisions of M.S. §§ 326.01 and 326.241-248 and Minn. Rules, Chapter 3800, including: (a) Compensation of any employee doing technology system work will be reported on an Internal Revenue Service W-2 form. (b) Where required, all technology system work will be performed by, or under the personal on-the-job supervision of properly licensed persons. One licensed person shall supervise no more three unlicensed persons as allowed by M.S. 326.242, subd. 5. (c) All advertising and business forms will be in the name shown on my contractor's license. (d) I will immediately notify the Department in writing of any change of address, telephone number, responsible power limited technician, employment of others, or other information required on my application. I hereby declare that any statements herein are true and complete, with the same force and effect as though given under oath.
DATE OF APPLICATION APPLICANT SIGNATURE

Provide signatures of all partnerships or of a limited liability partnership
PARTNER SIGNATURE

TITLE (Owner, Partner, Member, President, Vice President)

PARTNER SIGNATURE

PARTNER SIGNATURE

PARTNER SIGNATURE

Depositing of license fees does not constitute granting of the license applied for. This application will not be approved and the license applied for will not be renewed or issued unless all of the conditions identified on this application and in the M.S. §§ 326.01 and 326.241-248 and Minn. Rules, Chapter 3800 are complied with. 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.
TSC 01 (8/07)

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.htlm

Instructions for Completing Technology System Contractor Bond

THE ORIGINAL BOND FORM MUST BE FILED WITH THE APPLICATION – COPIES WILL NOT BE ACCEPTED. The Surety Company may use its own form. Regardless of whether the Department’s bond form is used or whether the Surety Company uses their own form, the expiration date for a Technology System Contractor Bond must be August 1, 2010. The bond shall be effective and run concurrently with the license period from the date the license is granted and shall expire on August 1, 2010. When the Department supplied bond form is used, it must be completed as follows: (Surety Company provided bond forms are completed in a similar manner with the same language that is on the Departments Bond form). Bond number: The Bond number must be issued. It cannot be marked "pending." The Business name including the assumed name (doing business as (dba)) shall be exactly the same as the applicant used on their "Technology System Bond Registration Form” and all other forms. The business name that an applicant uses to identify themselves must be filed or registered with the 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. See below examples: An individual without an assumed name - John Doe or John Doe Wiring An individual using their full true name as in the example above are not required to register with the Secretary of State An individual with an assumed name - John Doe dba Assumed Name A partnership with an assumed name - John Doe and James Doe dba Assumed Name A corporation - Company Name Inc. A corporation with an assumed name - Company Name Inc. dba Assumed Name A limited liability company - Company Name, LLC or LLP The address of the Business. The name of the Surety (Bonding) Company. The surety company’s address and telephone number. The state that the Surety Company is organized in. The date the Bond was signed and surety sealed by the power of attorney. Signature of Principal. If the Business is an individual owner, the owner must sign bond; if a partnership, all partners must sign bond; if a limited liability partnership, all partners must sign bond; if a corporation, an officer must sign bond; and if another business entity, a person with delegated authority must sign bond. The individual(s) signing the bond for the business must be identified as the Owners, all Partners of partnerships, all Officers of corporations (Inc), all Partners of limited liability partnerships (LLP) , all Limited Liability Company Members (LLC), and all Principals of other business types as listed on the Technology System Bond Registration Form. Name of Surety (Bonding) Company. Signature of Attorney in Fact (Surety Company). VERY IMPORTANT! The bond form must be notarized as follows: (A) or (B) AND (C) below A. If the business is an Individual, Partnership, or a Limited Liability Company, the bond form must be notarized in the block on the upper one-third of the form. ALL SIGNATURES NEED TO BE NOTARIZED. B. If the business is a Corporation, the bond form must be notarized in the block in the center one-third of the form. C. The block in the lower one-third of the form must be notarized by the Surety company. The original Power of Attorney form must be attached.
When the Surety Company completes the Bond, it must be returned to the Business to be signed by the principal. The Business shall have the Bond notarized on the back in the appropriate block (Box A or B). Bonds that have the conditions of the Bond modified in any manner will not be accepted, and the application will be returned to the submitter.
NOTE: DO NOT SEND BOND FORM TO THE DEPARTMENT OF LABOR OF INDUSTRY. BOND FORMS MUST BE SIGNED BY THE PRINCIPAL OF THE BUSINESS BEFORE SUBMISSION TO THE 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. Instructions LIC BD 09 (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

Technology System Contractor Bond
BOND NO. AMOUNT EFFECTIVE DATE

$25,000

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, are jointly and severally held and firmly bound to the state of Minnesota as obligee, in the sum of

TWENTY FIVE THOUSAND DOLLARS ($25,000) for the benefit of persons injured or suffering financial loss by reason of failure of such performance as herein specified for the payment of which, we bind ourselves, our heirs, executors, administrators, successors and assigns firmly by these presents. The bond shall be filed with the Minnesota Department of Labor & Industry and shall be in lieu of all other license bonds to any other political subdivision as provided in M.S. § 326B.33, subd. 6a.
The condition of the above obligation is such, that whereas, the said Principal is licensed as a Technology System Contractor. This bond shall constitute a new obligation in the sum of $25,000 for each biennial license period for which the Principal is licensed, provided, however, that the aggregate liability for the Surety to all persons for any one biennial license period shall in no event exceed the sum of $25,000. NOW THEREFORE, the condition of this obligation is that the Principal shall faithfully and lawfully perform all work entered upon by him as a Technology System contractor within the state of Minnesota, then this obligation to be void; otherwise to 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 which shall expire on August 1, 2008. During the term of this obligation the principal and surety will pay unto the obligee or as otherwise directed by the obligee the amount needed to correct non-complying work. The aggregate liability of the surety hereunder pertains to all claims arising during the period as defined above and shall in no event exceed the total sum of TWENTY-FIVE
Signed and sealed this day of

THOUSAND DOLLARS ($25,000). (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 09a (12/07)

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.

Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

Certificate of Insurance
Covering General Liability and Property Damage

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.

I hereby certify that
(Contractor Name as registered with the Office of the Secretary of State – see insurance instructions)

ADDRESS

CITY

STATE

ZIP CODE

is insured by
(Name and Address of Insurance Company)

, who is

licensed and/or authorized to do business in the state of Minnesota, providing general liability insurance (including premises and operations insurance and products and completed operations insurance) with limits of at least $100,000 per occurrence, $300,000 aggregate limits for bodily injury, and property damage insurance with limits of at least $25,000 or a policy with a single limit for bodily injury and property damage of $300,000 per occurrence and $300,000 aggregate limits under the provisions of
POLICY NUMBER FROM (month/year) TO (month/year)

(Name of Insurance Company)

hereby agrees that this policy will be kept in full force and effect with limits of at least the amounts stated above and will not be cancelled, terminated or non-renewed without the insurer giving 15 days written notice to the Department of such cancellation, termination or non-renewal. A renewal Certificate of Insurance will be issued upon the expiration date of this policy. I further certify that I
(Name - Please Print)

, am a of the above named insurance company

(Corporate Officer, Minnesota Resident Agent or Other Authorized Representative)

and that I am authorized to bind and hereby do bind it to insure as stated above and to issue this certificate on its behalf.

STATE OF

) ) ss

AUTHORIZED SIGNATURE OF INSURANCE AGENT/AGENCY

COUNTY OF

)

TITLE

On this personally came

day of

NAME OF INSURANCE AGENCY OR COMPANY

ADDRESS

(SEAL)

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

Signature of the Notary Public

Note: "Accord" form or "Accord" language cannot be accepted by the Department (M.S. § 326.242, subd. 6b)

ELI TSC 03 (5/06)

Instructions for Filling Out the Certificate of Insurance
FORWARD THESE INSTRUCTIONS TO YOUR AGENT WITH THE CERTIFICATE OF INSURANCE FORM. This form must be completed by the insurance company and not by the contractor. 1. The contractor name must be exactly the same as that the applicant used on their Application for Contractor's License form and all other forms. The contractor name that an applicant uses to identify themselves must be filed or registered with the 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. 2. Address of contractor (location from where the business is operated) 3. Name and address of Insurance Company 4. Must have "policy number," and coverage dates of insurance. 5. The name of Insurance Company 6. Name of person who certifies. (name of agent, corporate officer, or other authorized representative of agency) 7. Title of person who certifies. 8. Lower right-hand signature area, complete the following: Authorized Signature of the insurance agent/company (person identified in number 6 above) Title of Signer Name of Insurance Agency or Company Address City, State, Zip Telephone Number 9. Have signature notarized 10. "ACCORD LANGUAGE" IS UNACCEPTABLE. THE NOTICE OF CANCELLATION CLAUSE MUST BE UNCONDITIONAL AND PROVIDE FOR 15 DAYS ADVANCE NOTICE TO THE DEPARTMENT OF LABOR AND INDUSTRY. The paragraph under the name of the insurance company states that you "hereby agree that this policy will be kept in full force and effect with limits of at least the amounts stated above and will not be cancelled, terminated or nonrenewed without the insurer giving 15 days written notice to the Department of such cancellation, termination or nonrenewal." Some insurance companies have vague language on their forms such as: "we will try to or endeavor to mail a written notice to the Certificate holder 15 days before cancellation," and "if however, we fail to mail such notice, no obligation or liability will be imposed on the company."

Minnesota Statutes § 326.242, subd. 6(b) states in part: "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 Department 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 Department of such cancellation."

ELI TSC 03A (5/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198

Minnesota State Identification Information Form
Required for Contractor Application

PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

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. Failure to supply the required information may delay or prevent the Department from processing the original or renewal application and may result in a late fee being charged. Please supply the following information and return along with the contractor license application to: Construction Codes and Licensing, 443 Lafayette Road North, St. Paul, MN 55155-4342 The front page of this form must be completed for all business types. If the business is a partnership, corporation, or a limited liability company, one partner, officer, or member must complete this part of the form and the names, addresses, social security numbers, and signatures of all additional partners, officers, or members must be provided on the back of this form or, if additional space is necessary, on a separate form. All persons listed in Box 5 of the application form must furnish the identification information.
APPLICANT LAST NAME FIRST NAME MIDDLE INITIAL

APPLICANT ADDRESS

CITY

STATE

ZIP CODE

APPLICANT SOCIAL SECURITY NUMBER

APPLICANT POSITION (Individual, Partner, Officer, Member)

BUSINESS NAME (Must exactly match the name registered with the Office of Secretary of State or if not required to be registered, the contracting name)

BUSINESS ADDRESS

CITY

STATE

ZIP CODE

MINNESOTA IDENTIFICATION NUMBER

Note: A Minnesota Identification Number is required for all business types except for individual (sole proprietorship) or one-member limited liability company businesses that will not be making taxable sales and do not have employees. Minnesota Identification Numbers may be obtained from the Department of Revenue, 600 North Robert, St. Paul, Minnesota 55146. Telephone (651) 282-5225. (If making retail sales in Minnesota, call (651) 296-6181, the corporate and Sales Tax Division)

SIGNATURE (Owner, Officer, Partner, or Member)

DATE

ELI TSC 04 (5/06)

Other Partners, Officers, or Members
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.
APPLICANT LAST NAME FIRST NAME MIDDLE INITIAL

APPLICANT ADDRESS

CITY

STATE

ZIP CODE

APPLICANT SOCIAL SECURITY NUMBER

APPLICANT POSITION (Individual, Partner, Officer, Member)

APPLICANT SIGNATURE

DATE

APPLICANT LAST NAME

FIRST NAME

MIDDLE INITIAL

APPLICANT ADDRESS

CITY

STATE

ZIP CODE

APPLICANT SOCIAL SECURITY NUMBER

APPLICANT POSITION (Individual, Partner, Officer, Member)

APPLICANT SIGNATURE

DATE

APPLICANT LAST NAME

FIRST NAME

MIDDLE INITIAL

APPLICANT ADDRESS

CITY

STATE

ZIP CODE

APPLICANT SOCIAL SECURITY NUMBER

APPLICANT POSITION (Individual, Partner, Officer, Member)

APPLICANT SIGNATURE

DATE

APPLICANT LAST NAME

FIRST NAME

MIDDLE INITIAL

APPLICANT ADDRESS

CITY

STATE

ZIP CODE

APPLICANT SOCIAL SECURITY NUMBER

APPLICANT POSITION (Individual, Partner, Officer, Member)

APPLICANT SIGNATURE

DATE

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.

Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198
PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

Certificate of Responsible Licensed Power Limited Technician
THIS FORM MUST BE COMPLETED AND NOTARIZED BY THE RESPONSIBLE POWER LIMITED TECHNICIAN FOR THE CONTRACTOR

This is to certify that pursuant to M.S. § 326.242, subd. 6, I am the designated responsible power limited technician for the technology system contractor set forth below, and as such, I will be responsible for: 1. planning, laying out, and supervising all technology system work as required by M.S. § 326.242, subd. 1; 2. compliance with National Electrical Code safety standards as required by M.S. § 326.243; 3. ensuring that, when required, each job will be done by, or under the personal on-the-job supervision of, properly licensed employees of said contractor as required by M.S. § 326.242, subd. 5, and that one licensed person will supervise no more than three unlicensed persons on any job as allowed by M.S. § 326.242, subd. 5; 4. ensuring that a Request for Electrical Inspection or other inspection form is filed at or before the commencement of all technology system installations requiring inspection as required by M.S. § 326.244, subd. 2, and; 5. if I am not an owner or officer of the corporation holding said contractor's license, signing all Requests for Electrical Inspection as required by M.S. § 326.242, subd. 6. I understand that unless I am licensed as a power limited technician, and licensed as a contractor, doing business as an individual, as the responsible power limited technician for the contractor, I am prohibited by M.S. § 326.242, subd. 6c from being employed in any capacity as a licensed technician by any other contractor or employer. Unless I am licensed as a power limited technician and licensed as a contractor, doing business as an individual, I will notify the Department 15 days in advance of resigning as the responsible power limited technician with said contractor, or immediately upon termination by said contractor. I also understand that under M.S. § 326.242, subd. 9, the Department may revoke, suspend or refuse to renew any license granted pursuant to the Minnesota Electrical Act if a licensee knowingly and willfully makes a false statement in any license application or otherwise violates the requirements of the Minnesota Electrical Act and Minn. Rules chapter 3800.

COMPANY NAME OF TECHNOLOGY SYSTEM CONTRACTOR

ADDRESS

CITY

STATE

ZIP CODE

I PRESENTLY HOLD A POWER LIMITED TECHNICIAN LICENSE NUMBER

EXPIRATION DATE

STATE OF COUNTY OF Subscribed and sworn to before me this day of

) ) ss )

SIGNATURE OF POWER LIMITED TECHNICIAN

PRINTED NAME OF POWER LIMITED TECHNICIAN

ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE OF THE NOTARY PUBLIC

DATE

TELEPHONE NUMBER

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.
TSC 05 (6/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198

Affidavit of Exclusion from Requirements for Minnesota Identification Number

PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

I,
Name of Principal (Owner, Partner, Member, Officer)

, as a principal of

, an applicant for
(Name of Company)

a contractor license issued by Electrical Licensing and Inspection of the Department of Labor and Industry, certify that the contractor is not required to withhold Minnesota income tax from its employees on wages earned while performing work in Minnesota because of the following circumstance (check only one). The company is organized in a state other than Minnesota and its individual employees are not residents of Minnesota and will not earn more than $7,700 in wages any calendar year while working in Minnesota and therefore will not have a Minnesota individual income tax obligation, or The company is organized in Michigan, North Dakota, or Wisconsin* (states that have reciprocity agreements with the state of Minnesota) and its employees performing work are residents of one of these states and all employees earning wages while performing work in Minnesota have completed Form MWR, Reciprocity Exemption/Affidavit of Residency. Note: If a company organized in Wisconsin maintains a business office in Minnesota, it is required to have a Minnesota Identification Number regardless of the two circumstances identified above.

I further certify that I understand that if the identified circumstances change and the contractor is subsequently required to withhold Minnesota income tax from its employees, the contractor will obtain a Minnesota Identification Number and provide this number to Electrical Licensing and Inspection. I further understand that if the contractor fails to provide the Minnesota Identification Number when required, in addition to penalties that may be imposed by the Minnesota Department of Revenue, it is subject to disciplinary action from the Department of Labor and Industry as provided in M.S. § 326.242, subd. 9, including censure, denial, suspension, or revocation of the contractor's license and a civil penalty of up to $10,000 per violation.

STATE OF COUNTY OF On this personally came day of

) ) ss )

SIGNATURE OF PRINCIPAL

PRINTED NAME OF PRINCIPAL

TITLE OF PRINCIPAL

(SEAL)

PRINTED NAME OF COMPANY

SIGNATURE OF THE NOTARY PUBLIC

DATE

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.

ELI TSC 06 (5/06)

Minnesota Department of Labor and Industry Construction Codes and Licensing Division 443 Lafayette Road North St. Paul, MN 55155-4342 Phone: (651) 284-5064 Fax: (651) 284-5743 TTY/MRS: (651) 297-4198

Affidavit of Exclusion from Requirements for Workers’ Compensation Insurance

PRINT IN INK or TYPE your responses. Unreadable or illegible applications will be denied.

I,
Name of Principal (Owner, Partner, Member, Officer)

, as a principal of

, an applicant for
(Name of Company)

a contractor license issued by Construction Codes and Licensing of the Department of Labor and Industry, certify that all employees of the contractor meet one or more of the provisions of M.S. § 176.041 and are therefore excluded from the workers’ compensation requirements of Chapter 176. I further certify that if, during the term of the contractor license, the contractor employs any person who does not meet one or more of the provisions of M.S. § 176.041, the contractor will comply with the provisions of Chapter 176 and also provide Construction Codes and Licensing with the following information: (1) the name of the insurance company; (2) the workers' compensation policy number; and (3) dates of coverage. I further certify that I understand that if the contractor fails to provide workers’ compensation coverage when required, the contractor is subject to the penalty identified in M.S. § 176.182 as well as disciplinary action from the Department of Labor and Industry as provided in M.S. § 326.242, subd. 9, including censure, denial, suspension, or revocation of the contractor's license and a civil penalty of up to $10,000 per violation.

STATE OF COUNTY OF On this personally came day of

) ) ss )

SIGNATURE OF PRINCIPAL

PRINTED NAME OF PRINCIPAL

TITLE OF PRINCIPAL

(SEAL)

PRINTED NAME OF COMPANY

SIGNATURE OF THE NOTARY PUBLIC

DATE

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.

ELI TSC 07 (5/06)