HomeMy WebLinkAboutItem 06.dMay 21, 2012
Proposed Action
Staff recommends adoption of the following motion: Approve tree work license for
Custom Cut and Arbor Home Specialists.
Passage of this motion will result in issuing a tree work license for Custom Cut and
Arbor Home Specialists.
Overview
The City of Lakeville licenses companies that provide tree care (i.e. pruning, removal,
trenching, injections and stump removal) in the city.
Custom Cut and Arbor Home Specialists have submitted an application for a tree work
license.
Staff is recommending approval of a tree work license for Custom Cut and Arbor Home
Specialists.
Primary Issues to Consider
O Applicants paid fee and submitted Certificates of Insurance.
o Staff contacted the applicants and verified they are knowledgeable about arbor
practices and proper tree care.
Supporting Information
O Copy of Application for Tree Work License submitted by Custom Cut and Arbor
Home Specialists.
�L.
APPROVAL OF TREE WORK LICENSE
FOR CUSTOM CUT AND ARBOR HOME SPECIALISTS
O n Henrien
Park Maintenance & Operations Mgr
Item No.
Financial Impact: $ Budgeted: YIN Source:
Related Documents (CIP, ERP, etc.):
Notes:
3. Contact person:
4. Mailing address:
9. Number of vehicles:
APPLICATION FOR TREE WORK LICENSE
CITY OF LAKEVILLE
20195 Holyoke Avenue, Lakeville, MN 55044
952- 985 -4400
1. Business name: C k15 c,,0
2. Phone no: (U5\ )
;Ai'a��
Street
6, Business ownership: 2c Individual
8. Minnesota Tax Identification No. of business
(or Social Security No. if applicant is an individual):
F; c \1 Ci ar � �mfl % ‘
Title: vt
City
1 75V71
Zip
5. Person to be contacted in emergency: \ (k; �AK,v, 'o5 �r
Partnership Corporation
7. Number of employees:. List names of employees, partners or officers below:
10. Type of equipment to be used in business: Wm&
11. Will you be using chemical substances in any activity related to treatment or disease
control? YES NO (if YES, certification by the Agronomy Division of the
Minnesota Department of Agriculture as a "commercial pesticide applicator" must be attached.)
12. Please provide the following information related to workers' compensation insurance,
or certify the precise reason your business is excluded from compliance with the
insurance coverage requirement for workers' compensation.
Insurance company name (NOT agent):
Policy number or self-insurance permit number:
APPLICATION FOR TREE WORD LICENSE P age -2..
12. (CONTINUED)
Dates of coverage: to
(or)
I am not required to have workers" compensation liability coverage because:
I have no employees covered by the law.
) Other (Specify)
13. Proof of public liability insurance, covering all operations, for the sum of $300,000
combined single limit coverage must be attached.
14. Is your company licensed in any other city? If so, please list:
1 A5N∎
If not licensed in other cities
lease use the s aces above to list references and r hone numbers.
I, the undersigned, hereby certify that the above information, furnished by me, is true and
correct to the best of my knowledge. I further acknowledge that 1 have read and
understand the attached "Tree Preservation" and "Shoreland Impact" guidelines.
Au orize gnature
Title
TREEAPPL.doc(11 /22102)
Date: \\ -
ANNUAL FEE: $25.00
All Licenses Expire December 31st
8. Minnesota Tax Identification No. of business
(or Social Security No. if applicant is an individual): ,ay 35
1. Business name: , r`
iAL'xa2
2. Phone no: ( (cz3 ! ) 2& O -0721 Fax:
3. Contact person: 1/ Title: (,) , +.J tfz.,
4. Mailing address: 1121 -Cc_; Y f AL.* s 53
Street City Zip
5. Person to be contacted in emergency: vet - u 171-c+s
6. Business ownership: \K. Individual Partnership Corporation
7. Number of employees: 0 List names of employees, partners or officers below:
9. Number of vehicles: 3
APPLICATION FOR TREE WORK LICENSE
CITY OF LAKEVILLE
20195 Holyoke Avenue, Lakeville, MN 55044
952- 985 -4400
10. Type of equipment to be used in business: "l'e.,.,c.,F,5 1 Lamp E ,� '4>
11. Will you be using chemical substances in any activity related to treatment or disease
control? YES NO XI (If YES, certification by the Agronomy Division of the
Minnesota Department of Agriculture as a "commercial pesticide applicator" must be attached.)
12. Please provide the following information related to workers' compensation insurance,
or certify the precise reason your business is excluded from compliance with the
insurance coverage requirement for workers' compensation.
Insurance company name (NOT agent):
Policy number or self - insurance pennit number:
APPLICATION FOR TREE WORK LICENSE Page -2-
12. (CONTINUED)
Dates of coverage: to
(or)
I am not required to have workers' compensation liability coverage because:
) I have no employees covered by the law.
(�) Other (Specify)
13. Proof of public liability insurance, covering all operations, for the suin of $300,000
combined single limit coverage must be attached.
14. Is your company licensed in any other city? If so, please list:
/ z &zZ L t4 - r
PP - C lA f�r r�, J�+fcr2�ti�✓
If not licensed in other cities, please use the spaces above to list references and phone numbers.
I, the undersigned, hereby certify that the above information, furnished by me, is true and
correct to the best of my knowledge. I further acknowledge that I have read and
understand t,qie a r acb -+ "Tree Preservation" and "Shoreland Impact" guidelines.
e
Auth sized Signature
Title
FOR CITY USE ONLY
A.pProved DateFee Paid.
Date. _ .
- . .. ; ._.. ..
Ain
. , oust Paid: $
_ _.. Receipt No:
License No
TREEAPPL.doc(11 /22/02)
Date:
ANNUAL FEE: 525.00
All Licenses Expire December 31st