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Oct 3.8 OS 03:31p City of Falcon Heights 651644g6?S <br />City of ~'alcan H~i~'hts <br />MECIiAI~tICA,L CON'1`'kAC'I'pR ~ S LICENSE ~iPPLICATION <br />TO: Ci}y of Falcon rTeights <br />2G?? Wes*_ Larpenteur <br />Falcon Heights, MN 55:L2; <br />n52-H44-5050 <br />6~1-644-8675 ticzx <br />Firm I~?ame ; <br />busir_ess Addre`s/s, <br />"~.' f ~ <br />~~ <br />p.3 <br /> <br />L <br />Fee: 530.00 <br />Receipt ~ ~ ~~ <br />~a t e . /~ 3/zj <br />Expires: 12 ;~5 <br />ti <br />~p l ephon e : CS~~ ~ (~ ~~~ <br />Fax No; ~.~~- ..Z~l-- (~~/.~~~ <br />Name oi' Owner: - s•~ .5.~.; ~~ <br />Home ?address : ____~--~`- ~.~' ~2 <br />~-' ~ ~~"i ~~ ' {~'~~ ~. <br />Telep:1Gne: ~,.5`"/-,~ ~ L1I y,~ <br />City of St. Faul MPL T <br />/ S License Car~:ificati Jrl Number: <br />ti ]. ' f ~- • <br />~y c_ S.. Pau1,~NPLS . ,~cthex R7aj o~- City C of C Number : ~~_ <br />List Ycur Experience: <br /> <br />%$ <br />ITEPnS REQUIRED FOP, LICENSURE ; <br />• Insurance minimum of $300P000/$5,00,QU0.~~5~00,000 <br />tT:r_e city of Falcon. Heights should be named as additional <br />~ns~4red . ` <br />• Etate of Mir.~iesota TGa: TD B'o_rm <br />• ~>tate of Minnesota Workers ~ Compensa;.ion Fora, <br />• .~'.~oc~f cf insurance must .be fuxr~ished with aP.t~-'~-catiazs std <br />must iAdzcate IQ days scotsae before caracellatina. <br />I swear that the above s to te~ren is <br />are true to the best of my know.Zedge <br />and hel.i of .~~ <br />igna~ure `- • <br />