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Rug 08 05 07:40a <br />City of Falcon Heights 6516448675 <br />City of Falcon Heights <br />MECHANICAL CONTRACTOR S LICENSE APPLICATION <br />T0: City of Falcon Heights <br />2077 West Larpenteur <br />Falcon Heights, MN 55113 <br />651-644-5050 <br />651-644-8675 (f~) <br />Firm Name : ~ ~. ~ < <br />Business Address : / ~ ;~ ~ ~.~+ ~~/_a <br />p.3 <br />Fee: $30.00 <br />Receipt # <br />Date : ~ ._.O ~' <br />Expires: 12 31 05 <br />VLF <br /> <br />~ ~~ ~ ~~U~ <br />Telephone: `11~3_y~)~~~~ ~ <br />Fax No : ~_~y ark ~, r~ <br />Name of Owner ; „~ ~, ,~ /~/ ~ --'--- <br />1L /c .~,V <br />Home Address : ~c ~ ~~y, /~f n <br />Telephone: `~~~_~~/_~`~s'~ ~ <br />City of St. Paul/MPLS License Certification Number: <br />City of St. Paul/MPLS./other Major City C of C Number: <br />List Your Experience: ~~~ ~ <br />~3~'°~-, <br />ITEMS REQUIRED FOR LICENSURE: <br />• Insurance minimum of $300,OD0/$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 i,asur8ace ,roust be furnished with a <br />must indicate 10 days aotice before ca-acel stiosi tioa and <br />I swear tha t the above s to t emen is <br />are true to the best of my knowledge <br />and bet i of . <br />gna <br />C7 <br />lJ <br />• <br />