2B, EAB Draft Implementation Plan

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2012- -A EN HILLS Payment Method _..............: ---................... 2012 City Contractors Receipt#.. 1245 West Hwy 96 _.. Arden Hills 55112 License (�50 Fee) Date Paid *F Phone 651.792.7800*Fax 651.634.5137 www.ci.arden-hills.mn.us License Type: ❑Commercial ❑Mechanical**must attach a copy of your current state surety bond** ❑Specialty(describe) (All information requested is required.) Company Name: Address: City/State/Zip: Email Address: Phone#: Federal Tax ID#: Fax#: MN Tax ID#: Applicant Name SSN: -- Required Submittals: ■ Payment of$50 (enclose check or pay by credit card in person) ■ Attach a Certificate of Liability Insurance of at least$100,000 for bodily injury to any one person,including accidental death,and not less than$300,000 aggregate;property damage liability of at least$100,000 for each accident and not less than$100,000 aggregate. ■ Attach a Certificate of Worker's Compensation to the minimum acceptable levels of the State of Minnesota. OR: Sign Worker's Compensation Waiver: Worker's Compensation Wavier If you are a sole proprietor and have chosen not to carry worker's comp,the following waiver must be signed: As a sole' proprietor or partnership, I/we have chosen not to carry Workers Compensation Insurance on myself/ourselves Authorized Signature Date NOTICES AND AUTHORIZATIONS. No work shall be done under this license until the insurance policies have been filed and approved by the City of Arden Hills Code Enforcement Division. Pursuant to Laws of Minnesota,1984,Chapter 502,Article 8,Section 2(270.72)(Tax Clearance;Issuance of Licenses),the City of Arden Hills is required to provide to the Minnesota commissioner of Revenue the Minnesota business tax identification number and social security number of each applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974,we are required to advise you of the following regarding the use of this information: * This information may be used to deny the issuance or renewal of your license in the event you owe Minnesota sales,employer's withholding or motor vehicle excise taxes; * Upon receiving this information,the City of Arden Hills will supply it only to the Minnesota Department of Revenue;however,under the Federal Exchange of Information Agreement,the Department of Revenue may supply this information to the Internal Revenue Service; * Failure to supply this information may jeopardize or delay the processing of your license issuance or renewal application. The above signed applicant makes this application pursuant to all the laws of the State of Minnesota and such rules and regulations as the Council of the City of Arden Hills may from time to time prescribe. The above-named firm hereby applies for a license for the term of one year,this term beginning January 1,2012 to December 31,2012,with the City of Arden Hills,Minnesota. Applicant Signature ___----------------------------------------- Date .............