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City of Falcon Heights <br />MECHANICAL CONTRACTOR'S LICENSE APPLICATION <br />• TO: City of Falcon Hei ht <br />g s Fee: $30.00 <br />2077 West Larpenteur Receipt ## <br />Falcon Heights, MN 55113 <br />651-644-5050 Date: ~~'=~ <br />651-644-8675 (fax) <br />~` ,~^ ~ > Expires : 12 31 05 <br />Firm Name : d fJ" r' . J G, ~/ ~~ ~~ <br />C. f Uz ry ~ /`+ <br />Business Address : ~ ~~ x~ ~ ~'~ <br />Telephone : ~ Z~ ,~ `f ~ Z ,Z ~ Fax No <br />Name of Owner: ~~ u ~ -r~-'~' ~ ~ j~~~ <br />Home Address: %~ <br />Telephone : ~ 2 Cy ~ ~~ 2 ~ .3 C~ <br />~- 'f ~ <br />~•~ ~~~ <br />S ~ ~!b <br />~! ~ ~, <br />City of St. Paul/MPLS License Certification Number /' (~ 7 6` U <br />City of St. Paul/MPLS./other Major City C of C Number: <br />• List Your Experience : `.~J ~ ~ ~~ <br />ITEMS REQUIRED FOR LICENSURE: <br />• Insurance minimum of $300,000/$500,000/$100,000 <br />(The city of Falcon Heights should be named as additional <br />insured.) <br />• State of Minnesota Tax ID Form <br />• State of Minnesota Workers' Compensation Form <br />• Proof of insurance must be furnished with application and <br />must indicate 10 days notice .before cancellation. <br />I swear tha t the above s to temen is <br />are true to the best of my knowledge <br />and belief. <br />Si nature <br />