HomeMy WebLinkAboutItem 06.dOctober 4, 2012 Item No.
TREE WORK LICENSE FOR PETERSON TREE SERVICE
Proposed Action
Staff recommends adoption of the following motion: Move to approve tree work license for
Peterson Tree Service.
Passage of this motion will result in issuing a tree work license for Peterson Tree Service.
Overview
The City of Lakeville licenses companies that provide tree care (i.e. pruning, removal,
trenching, injections and stump removal) in the City.
Peterson Tree Service has submitted an application for a tree work license.
Staff is recommending approval of a tree work license for Peterson Tree Service.
Primary Issues to Consider
• Applicant paid fee and submitted Certificate of Insurance
• Staff contacted the applicant and verified they are knowledgeable about arbor practices
and proper tree care
Supporting Information
• Copy of Application for Tree Work License submitted by Peterson Tree Service
J n Hennen
nterim Parks & Recreation Director
Financial Impact: $ Budgeted: Y/N Source:
Related Documents (CIP, ERP, etc.):
Notes:
APPLICATION FOR FREE WORK LICENSE
CITY OF LAKEVILLE
20195 Holyoke Avenue, Lakeville, ,MN 55044
952- 985 -4400
1. Business name: [ T,.,. y v i r1
2. Phone no; G 5Z ) (o o =_c> I Fax:
3. Contact person: , ��,,.� Title: D )L)E
r. Mailing address: if I L4 Im e""'e Li�6 f f 3 9'j
Street City Zip
S. Person to be contacted in emergency: _ t J OM f
6. Business ownership: Individual Partnership Corporation
7. Number of employees: , t List names of employees, partners or officers below:
8. Minnesota Tax Identification No. of business
(or Social Security No. if applicant is an individual): HIq -
9. Number of vehicles:
I0. Type of equipment to be used in business;
I l Will you be using chemical substances in any activity related to treatment or disease
control? YES NO If YES certification by flle Agronomy. Division of the
Minnesota Department of Agriculture as a "commercial pesticide applicator" must be attached.)
12. Please provide the fallowing 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 (MOT agent): t�-O K er -
el Se n N s
Policy number or self-insurance permit number: 5 o ���
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) a,�I,' ?� oc-y/1 &
13. Proof of public liability insurance, covering all, operations, for the sum of $300,000
CG �1lbl.f.led JLLJ.��'I� llritlt LUVorLL�yG i11UJt U tLLLi1t:II.CCt.
14, Is your company licensed in any other city? If so, please list:
If not liven ed in other cities jRlease use the s aces above to list references and. Dhone 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 the attached "Tree Preservation" and "Shoreland Impact" guidelines.
A At - _ Date: t
Aut arized Signature
Mja "
Title
ANNUAL FEE: $25.00
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TREEAPPL.doc(1 1122/02)