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OCT 19 2005 11:24 <br />Qct IB OS d3:52p <br />HP LFiSERJET 3200 <br />gg18448675 <br />Cites of Fatcvn Heights , <br />p.2 <br />p.2 <br />C~,~y of Falcoa Heights <br />IdECSAN=CAL CONTg,ACTOR' S LICSNSB APPLICi~~TION <br />TO: City of Falcon geigttts <br />2077 West Larpenlt+INeu55113 <br />Fal-con Heicthts, <br />651-644-5050 <br />651-644-8675 (fax) <br />Firm Name: ~~ ~~ <br />Business P,ddress <br />TelephQne :- <br />F,ae: $3Q.00 <br />Recei;~~t # <br />Date <br />Expix:=s : ~ <br /> <br /> <br />~, ~ ~~ E <br />Fax No : ~~" ~ ~? ~ ~~~ <br />Name of Owner: <br />t~~ <br />Home Address : ~ c,~~ (O <br />Telephone : -~ ~ dag ~Cb~ <br />City of St. Paul PZS icenae Certification Number: _~ <br />v~g <br />Cit o St. Paul MPLS./other Major City C of C PRtmber: ~ ~ <br />Y <br />Lief Your Experience: <br />ITEMS 1~E~UTRED FOR LICEN3URF: <br />• Insurance.. m~-r~i-~-um of- $30Q, 000($500, aool$loa, o00 <br />(The city of Falcon Heights should be named as add:..tional <br />insured.) ~ ~ - <br />State of Minnesota Tax ID Form <br />~ gt atP ofr Minnesota Workers' ComFensation Form <br />prof of insurance inuat be tu~3shed with applicati~an and <br />must .indicate 30 days aotiee before caaaellation. <br />Y swear that. the. abave eta:::~enr,.s <br />are true tv the best of mY knawl edge <br />and lief. <br />Signature <br /> <br />