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Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5065

Residential Building Contractor or Remodeler License Application PRINT IN INK or TYPE your responses

The data that you furnish on this form will be used by the Department of Labor and Industry to assess your qualifications for a license. Disclosure of your Social Security number is voluntary. You are not legally required to provide this data; however, if you do not provide your Social Security number, the Department of Labor and Industry may be unable to grant a license. The department may use Social Security numbers for revenue recapture as authorized by Minnesota Statutes, Chapter 270A, and for identification purposes. After issuance of a license, all information contained in this application, except your Social Security number, is public pursuant to Minnesota Statutes, Chapter 13.

Make a copy of this application for your records. TYPE OF LICENSE

Residential Building Contractor Residential Remodeler

FEES If gross receipts are less than $1,000,000................................. Total fee is $200 If gross receipts are $1,000,000 to $5,000,000 ......................... Total fee is $250 If gross receipts are more than $5,000,000............................... Total fee is $300

All licenses EXPIRE on March 31 of each year, regardless of when the original license is issued. To maintain an active license, all licenses must be RENEWED by March 31 of each year, whether the license was issued for all or a portion of the license period. All license renewals require seven hours of continuing education.

Is this application submitted due to business structure change? Yes No If yes, provide previous license number:

Is this application submitted for late renewal? Yes No If yes, provide current license number:

BUSINESS INFORMATION Check appropriate box below (Individual Proprietor or Business Entity) and submit required documentation as indicated INDIVIDUAL PROPRIETOR LAST NAME

FIRST NAME

MIDDLE NAME

DBA (If DBA name is different from legal name listed above, attached a Certificate of Assumed Name filed and stamped by the Minnesota Secretary of State) STREET ADDRESS (PO Box must include RR# or street address) DATE OF BIRTH (mo/day/yr)

CITY

BUSINESS PHONE NUMBER

STATE

ZIP CODE

SOCIAL SECURITY NUMBER

Individual Instructions: 1. Attach a copy of Certificate of Assumed Name (if DBA name is different from legal name of individual). 2. Attach a completed BCA form for the individual listed above. BUSINESS ENTITY LEGAL NAME OF CORPORATION, PARTNERSHIP OR OTHER BUSINESS ENTITY DBA (If DBA name is different from legal name listed above, attached a Certificate of Assumed Name filed and stamped by the Minnesota Secretary of State) Check one:

General partnership Corporation

Limited partnership Limited liability company

Limited liability partnership Other (specify ______________________

BUSINESS ADDRESS (PO Box must include RR# or street address) CITY

STATE

ZIP CODE

MINNESOTA TAX IDENTIFICATION NUMBER (To apply for a tax ID#, contact the Dept. of Revenue at (651) 282-5225). BUSINESS PHONE NUMBER

Instructions for Business Entities: 1. Attach a copy of Articles of Incorporation or other business organization documents, filed and stamped as required by Minnesota Secretary of State, or Partnership Agreement signed and dated by all partners. 2. Attach a copy of Certificate of Assumed Name (if DBA name is different from legal name of business entity or if DBA name does not include each partner’s full name). 3. Attach completed Disclosure of Owners, Partners, Officers form. 4. Attach a completed BCA form for each individual listed on the Disclosure of Owners, Partners, Officers form. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. Office Use Only

RBC 08 (12/06)

PROCESSING DATE

LICENSE NUMBER

Page 1 of 3

COMPANY NUMBER


INSURANCE INFORMATION LIABILITY INSURANCE: Name of insurance company Attach Certificate of Insurance showing liability insurance coverage with limits of $100,000 per occurrence, with $10,000 property damage coverage. Name and address of “insured” on Certificate of Insurance must be the same as the name and address of company as listed in this license application. “Certificate holder” section of Certificate of Insurance must state: Minnesota Department of Labor and Industry, Residential Contractor, 443 Lafayette Road N., St. Paul, MN 55155

WORKERS’ COMPENSATION INSURANCE: Name of insurance company Attach Certificate of Insurance showing workers’ compensation coverage. For information regarding workers’ compensation requirements, contact the Minnesota Department of Labor and Industry at (651) 284-5005. If exempt, attach a written explanation of the specific exemption, signed and dated by applicant. Name and address of “insured” on Certificate of Insurance must be the same as the name and address of company as listed in this license application. “Certificate holder” section of Certificate of Insurance must state: Minnesota Department of Labor and Industry, Residential Contractor, 443 Lafayette Road N., St. Paul, MN 55155

UNEMPLOYMENT INSURANCE: Unemployment insurance account number For information regarding unemployment insurance requirements, contact the Minnesota Department of Employment and Economic Development at (651) 296-6141. If exempt, attach a written explanation of the specific exemption, signed and dated by applicant. QUALIFYING PERSON INFORMATION LAST NAME RESIDENTIAL STREET ADDRESS PHONE NUMBER

FIRST NAME

MIDDLE NAME CITY

SOCIAL SECURITY NUMBER

STATE

ZIP CODE

DATE OF BIRTH

Title of qualifying person (check one) Owner of individual proprietorship

Chief executive officer of corporation

General partner

Chief manager of L.L.C.

Managing employee who is regularly employed by the applicant and is actively engaged in the business of residential contracting or residential remodeling on behalf of the applicant. Examination 1.

Attach the qualifying person’s original passing examination results.

2. 3.

Date of passing exam: Examination results expire after two years. If the examination was taken more than two years prior to this application, attach Course Completion Certificate(s) documenting seven hours of continuing education for each license period after the expiration of the examination results. List the qualifying person’s business and/or employment history for the past five years. Attach additional pages if necessary. DATES OF EMPLOYMENT BUSINESS NAME DESCRIPTION OF EMPLOYMENT From To

Is the qualifying person a qualifying person for more than one licensed corporation? Yes No If “yes” is checked, indicate the company name of the other licensed corporation for which this individual acts as a qualifying person: Affiliated corporation name Affiliated corporation license number To be a qualifying person for two corporations, one of the following affiliations must exist. Please check the appropriate affiliation below: there is a common ownership of at least 25 percent of each licensed corporation for which the person acts in a qualifying capacity; or one corporation is a subsidiary of another corporation for which the same person acts in a qualifying capacity. “Subsidiary” means a corporation of which at least 25 percent is owned by the parent corporation. Page 2 of 3


All applicants must answer questions 1 through 11. Answer “yes” if the applicant or the applicant’s qualifying person, owners, partners, officers, directors, shareholders owning more than 10 percent of the corporation’s stock, LLC owners/governors, managers or employees exercising management or policy control, have ever: 1.

Held a residential building contractor, remodeler, roofer, manufactured home installer or any other occupational, professional license in any state including Minnesota? If yes, list the state(s) below and the license type(s) for each state where you have held a license. ______________________________________________________________ ____________________________________________________________________________________________

Yes

No

Been the subject of any inquiry or investigation by any division of the Minnesota Department of Commerce, Minnesota Department of Labor and Industry, or Office of the Attorney General? If yes, attach a written explanation signed and dated by applicant, including specific dates, and submit copies of all letters of inquiry and resolution.

Yes

No

Yes

No

Been charged, indicted, pleaded to or convicted of any criminal offense in any state or federal court in the past 10 years? Include felonies, gross misdemeanors or misdemeanors; do not include traffic violations. If yes, you must attach: a) a written statement, signed and dated by applicant, explaining the circumstances of each incident; b) a copy of the charging document; c) a copy of the official document that establishes the resolution of the charges or any final judgment; and d) if currently on probation, attach a letter from probation officer stating your compliance with terms of probation.

Yes

No

Been a defendant in any lawsuit or been named in a civil judgment, involving claims of fraud, misrepresentation, conversion, mismanagement of funds, breach of fiduciary duty or breach of contract? If yes, attach written explanation signed and dated by the applicant, including specific dates, and submit copies of legal resolution.

Yes

No

Been notified by the commissioner of the Department of Revenue, pursuant to Minnesota Statutes, Section 270.72, that you currently owe the State of Minnesota any delinquent taxes? If yes, attach written explanation signed and dated by applicant, including specific dates.

Yes

No

Exercised management or policy control over, or owned 10 percent or more of the stock of any company that has failed in business or filed a bankruptcy petition or been declared bankrupt? If yes, list the company name(s) and attach copy of the company’s bankruptcy disposition: __________________________________________________ ____________________________________________________________________________________________

Yes

No

Been the subject of any outstanding unsatisfied judgment(s) relating to any residential contracting or residential remodeling, residential roofing or manufactured home installer activities? If yes, attach written explanation signed and dated by applicant, stating the reason for the outstanding judgment and the amount of the judgment and including specific dates, and submit copies of legal resolution

Yes

No

Owned or controlled a business entity that has undergone a change in name, ownership or control, or has there been a sale or transfer of the applicant’s business entity in the past five years? If yes, attach a list of the names and addresses of all prior, predecessor, subsidiary, affiliated, parent or related entities, and whether each such entity or its owner, officers, directors, members or shareholders hold more than 10 percent of the stock would have answered yes to questions 1 through 8.

Yes

No

10. Currently possess any unclaimed property (unclaimed funds or property more than three years old) that has not been reported as required by Minnesota Statutes, section 345.37?

Yes

No

11. Indicate whether anyone listed below has ever been affiliated with a residential contractor, remodeler, roofer or manufactured home installer business that engaged in any activity that would result in a yes answer to the above questions 1 through 8: the applicant or the applicant’s qualifying person, owners, partners, officers, directors, employees exercising management or policy control, managers, L.L.C. owners/governors or shareholders owning more than 10 percent of corporate stock.

Yes

No

2.

3. Had any occupational, professional or vocational license or permit censured, suspended, revoked, canceled, terminated or been the subject of any type of administrative action in Minnesota or any other state? If yes, you must attach: a) a written statement, signed and dated by applicant, explaining the circumstances of each incident; b) a copy of the Notice of Hearing or other document that states the charges and allegations; and c) a copy of the official document that establishes the resolution of the charges or any final judgment. 4.

5.

6.

7.

8.

9.

CERTIFICATION I certify all of the information submitted in this application and attachments is true and complete, and that this document has not been changed in any manner from the form adopted by the Department of Labor and Industry. SIGNATURE OF OWNER, PARTNER, OFFICER (mandatory)

TITLE

SIGNATURE OF QUALIFYING PERSON (mandatory)

DATE DATE

Page 3 of 3


Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5065

Disclosure of Company Owners, Partners, Officers

NAME OF COMPANY PRINT IN INK or TYPE your responses An applicant for a company license must provide the following information: • Individual proprietor: Provide the name and address of the owner. • Partnership: Provide the name and address of all general partners and limited partners. • Corporation, L.L.C., Trust, other: Provide the name and address of all elected officers, directors, governors, members, shareholders owning 10 percent or more of company stock, and any managers/employees with authority to exercise control in policy or management of the company. • Governmental entity: Provide the complete name and address of the government agency that owns the company and any directors/managers/employees with authority to exercise control in policy or management of the company. If any owner or partner is also a business entity, you must complete this form to disclose the owners/partners/officers/shareholders of that business entity as well.

NAME STREET ADDRESS TITLE (check one) 100 percent owner

CITY

General partner

Limited partner

Elected officer (title: ______________________)

STATE

Director

ZIP CODE

Manager/employee with controlling authority

Shareholder (percentage of ownership: _____)

L.L.C. governor/member

NAME STREET ADDRESS TITLE (check one) 100 percent owner

CITY

General partner

Limited partner

Elected officer (title: ______________________)

STATE

Director

ZIP CODE

Manager/employee with controlling authority

Shareholder (percentage of ownership: _____)

L.L.C. governor/member

NAME STREET ADDRESS TITLE (check one) 100 percent owner

CITY

General partner

Limited partner

Elected officer (title: ______________________)

STATE

Director

ZIP CODE

Manager/employee with controlling authority

Shareholder (percentage of ownership: _____)

L.L.C. governor/member

NAME STREET ADDRESS TITLE (check one) 100 percent owner

CITY

General partner

Limited partner

Elected officer (title: ______________________)

STATE

Director

ZIP CODE

Manager/employee with controlling authority

Shareholder (percentage of ownership: _____)

L.L.C. governor/member

NAME STREET ADDRESS TITLE (check one) 100 percent owner

CITY

General partner

Limited partner

Elected officer (title: ______________________) SIGNATURE OF OWNER/PARTNER/OFFICER

STATE

Director

ZIP CODE

Manager/employee with controlling authority

Shareholder (percentage of ownership: _____) TITLE

L.L.C. governor/member DATE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. RBC 09 (12/06)

This form may be photocopied if additional forms are needed.


Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5065

BCA FORM Bureau of Criminal Apprehension Criminal Background Check

PRINT IN INK or TYPE your responses THIS FORM MUST BE COMPLETED AND SIGNED BY ALL INDIVIDUAL APPLICANTS; IF THE LICENSE IS TO BE ISSUED TO A COMPANY, THIS FORM MUST BE COMPLETED AND SIGNED BY EACH OF THE COMPANY’S OWNERS, QUALIFYING PERSON, LIMITED OR GENERAL PARTNERS, CORPORATE OFFICERS, DIRECTORS, SHAREHOLDERS OWNING MORE THAN 10 PERCENT OF THE CORPORATION’S STOCK, L.L.C. OWNERS/GOVERNORS, MANAGERS OR EMPLOYEES WITH AUTHORITY TO EXERCISE MANAGEMENT OR POLICY CONTROL. THE DEPARTMENT OF LABOR AND INDUSTRY REQUIRES THIS INFORMATION TO CONDUCT CRIMINAL HISTORY CHECKS AND/OR VERIFY TAX IDENTIFICATION INFORMATION.

TO:

Bureau of Criminal Apprehension and Minnesota Department of Revenue

RE:

Request for criminal background check and request for disclosure/verification of tax identification number

PROVIDE PERSON’S COMPLETE LEGAL NAME LAST NAME (if legal list name is hyphenated, enter both names here)

FIRST NAME

ADDITIONAL MIDDLE NAME (if applicable)

MIDDLE NAME

MAIDEN NAME (if applicable)

DATE OF BIRTH (mo/day/yr)

FORMER LIST NAME or OTHER NAME (if applicable)

SOCIAL SECURITY NUMBER

TYPE OF LICENSE FOR WHICH YOU ARE APPLYING

THE FOLLOWING SECTION MUST BE COMPLETED IF THE LICENSE IS TO BE ISSUED TO A COMPANY NAME OF THE COMPANY

COMPANY’S ASSUMED NAME (if applicable)

COMPANY’S MINNESOTA TAX IDENTIFICATION NUMBER

YOUR TITLE OR POSITION IN THE COMPANY

CERTIFICATION AND AUTHORIZATION: •

I, the undersigned, and my company have made application to the Minnesota Department of Labor and Industry for a regulated professional or occupational license.

I certify that complete and accurate responses have been provided for all questions on the application.

I hereby request and authorize the Bureau of Criminal Apprehension to conduct a background check of me through their records for licensing purposes.

I hereby request and authorize the Minnesota Department of Revenue to disclose or verify the state tax identification number.

SIGNATURE (mandatory)

DATE

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. RBC 07 (12/06)


Minnesota Department of Labor and Industry CCLD Licensing and Certification/Residential 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5065

Residential Building Contractor and Remodeler Checklist

Please note: Fees cannot be prorated for licenses issued for a portion of the license period. (The license period is April 1 through March 31.) Fees are the same no matter when a license is obtained during the 12-month license period.

If gross receipts are: Recovery fund fee License fee Total fee due Less than $1 million $100 $100 $200 $1 million to $5 million $150 $100 $250 More than $5 million $200 $100 $300 Structure change requires a new application and new fees. If you make a structure change to your business, you have created a new entity and the full application fee must be paid whenever the structure change takes place.

Fee: The total fee due is based on the applicant’s gross annual receipts (see fee chart above). Enclose one check payable to the Minnesota Department of Labor and Industry. Attach the qualifying person’s passing test results. Attach completed Bureau of Criminal Apprehension forms for the applicant and the qualifying person. Attach the Certificate of Assumed Name if applicable, and be sure the DBA name on the license application is identical to the name listed on the Certificate of Assumed Name. Attach required documents and written explanation for any questions answered “yes” on the application. Attach Certificate of Insurance for $100,000 per occurrence liability insurance policy with at least $10,000 of property damage coverage. Attach Certificate of Insurance for workers’ compensation insurance coverage. Be sure the “insured” section on each Certificate of Insurance shows exactly the same company name listed on your license application. Be sure the “Certificate holder” section on each Certificate of Insurance shows: Minnesota Department of Labor and Industry, Residential Contractor, 443 Lafayette Road N., St. Paul, MN 55155. Sign and date the application. Mail all documents and fee check to address above. License will be mailed to business address after application processing. Note: Application processing is not currently available at the DLI public service counter. Note:

Secretary of State business filing and Assumed Name Certificate application information is available via telephone (651) 296-2803, or online at www.sos.state.mn.us.

CORPORATIONS Attach a copy of Articles of Incorporation or Certificate of Incorporation, stamped and filed with the Minnesota Secretary of State. Attach a Certificate of Assumed Name, stamped and filed with the Minnesota Secretary of State, if the DBA is different from the corporate name. Attach completed Bureau of Criminal Apprehension Criminal Background Check forms for all corporate officers, directors and shareholders owning more than 10 percent of the outstanding stock in the corporation. PARTNERSHIPS Attach a partnership agreement that lists the names and addresses of each partner, amount of ownership, signed and dated by each partner. Attach completed Bureau of Criminal Apprehension Criminal Background Check forms for all partners. REMINDER All licenses expire March 31 of each year, no matter when the license is issued. To maintain an active license, all licenses must be renewed by March 31 each year, whether the license is issued for all or a portion of the license period. (The license period is April 1 through March 31.) To renew your license each March 31, you must complete seven hours of continuing education before the renewal date. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. RBC 10 (12/06)

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