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City of Falcon. Heights <br />f U <br />MECHANICAL CONTRACTOR'S LICENSE APPLICATION <br />• <br />TO: City of Falcon Heights Fee: $30.00 , <br />2077 West Larpenteur Receipt # ~~~~~' <br />Falcon Heights, MN 55113 Date: 3i~^ <br />651-644-5050 <br />651-644-8675 (fax) Expires: 12/31/05 <br />Firm Name : ~rM ; ~ 1~~ ~~' '~' ~~' <br />Business Address : ~~~ ~ f~-v~y~l~" ~~ <br />~~15, ti1~ 5~~~ <br />Telephone : ~5 /~ ~ j ~° ~~ ~~ Fax No : ~~ 9~ ~ ~~"~' ~~ ~~ <br />Narne of Owner : r~=`~~--+~ 5~ 1/ <br />Home Address : ~ ~~~ ~ ~ ~ ~` <br />Telephone : ~~ " ~~~ <br />City of St . Paul/MPLS License Certification Number: Gll~ ~~~~/~ <br />City of St. Paul/MPLS./other Major City C of C Number: <br />List Your Experience: <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 insuraztee must be furnished with application and <br />must indicate 1Q days notice before cancellation. <br />I swear that the above statements <br />are true to the best of my knowledge <br />and belief. <br />r/ <br />t~,,vru ~%1~ ~f2~. GLr <br />Signature <br />• <br />I'd SL98b~9iS9 s~y~taH uvvte~ ,i.o R~iO e~,S:gO SO iE end <br />