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HomeMy WebLinkAbout2009 - Outdoor Ads IncCity of OMW heat Pe LICENSEOffice Use),: COMMUNiTy DEVELOPMENT LICENSE( 7500 W 29th Avenue, Wheat Ridge, CO 80033 R E C, 4ffiIVED Lic # P: 303.235.2855 F:303-237-8929 Email: contractors(cD-ci.wheatridge.co.us ' APPLICATION FOR BUILDING CONTRACTORSttCENSE The undersigned affirms that he/she is knowledgeable of the ordinances and regulations of the City of Wheat Ridge relative to building & construction within the City and shall at all times perform in compliance with same as a contractor under the class of license hereby applied for: Lic. Class/Description Fee Lic. Class/Description Fee Class 1 — Unlimited $150.00 Class 8 — Plumbing $100.00 See Page 4 for licensing requirements See Page 5 for licensing requirements Class 2 — Limited $125.00 Class 9 — Mechanical $100.00 See Page 4 for licensing requirements See Page 5 for licensing requirements Class 3 — Residential $100.00 Class 10 — Electrical*DO NOT USE THIS FORM See Page 4 for licensing requirements Class 11 — Sign $75.00 Class 4 — Subcontractors $75.00 All subcontractors or trades not authorized Class 12 — Fire Protection $75.00 under other license classes Type: Class 13 — Lawn Sprinkler $75.00 Class 5 — Homeowner No Fee Class 14 — Roofing $75.00 Testinq may be required See Page 6 for licensing requirements Class 6 — Structure Moving $75.00 Class 16 — Electrical Signal $75.00 (Systems < than 50 volts) Class 7 — Demolition $75.00 BUSINESS NAME 1 �' OWNER(S) NAME(S) ADDRESS AA r1 PHONE S - -� V—s. EMAIL /_JA6vt.%1% **USE INK ��T+,,OCOMPLETE THIS FORM** 117 % �F :D —Z�lf!�' � If corporation, provide EIN �C 1 13-C% ITY CELL The following documents must accompany this application or it will not be processed: -Copy of corresponding licensing requirement for license class selected -Copy of Insurance certificate per insurance requirements on Page 4 -Form of Payment (application will not be processed via email without a credit card authorization form included) *Complete all information on all pages. Sign and date application on Page 6 Name(s) of owner(s) Home Address Phone number: Signature: Name(s) of owner(s) Home Address Phone number: Signature: Name(s) of owner(s) Home Address _ Phone number: Signature: Name: Home Address_ Phone number: Signature: Name: Home Address Phone number: Signature: Name: Home Address Phone number: Signature: Name: Home Address_ Phone number: Signature: *Complete all information on all pages. Sign and date application on Page 6 2 (6) Structure Moving Contractor - Class 6, shall authorize moving of any and all types of buildings or structures. The requirement for license applies to any person so performing in the city on public rights-of-way regardless of points of beginning and destination of the performance. (see section 5-42 for insurance and bond requirements) Documents required: Provide copies of three active subcontractor type licenses with any three municipalities in Colorado. (7) Demolition Contractor - Class 7, shall be authorized to perform demolition or wrecking of any building or structure or portion thereof. Documents required: Provide copies of three active subcontractor type licenses with any three municipalities in Colorado. (8) Plumbing Contractor - Class 8, shall be authorized to do the following: installation of all sanitary plumbing and potable water supply piping and appliances connected thereto, and including gas piping and the complete installation of water heaters, the installation of piping for transmission of chemicals and gases; the installation and removal of backflow prevention devices; the installation of gas ranges, gas dryers and gas refrigerators, steam and hot water heating system, process and industrial piping and related appurtenances which shall include the piping used for the transmission of chemicals and gases, the installation of burners, piping and controls utilizing gas, pipe insulation and low voltage wiring which does not exceed fifty (50) volts and when such wiring is not enclosed in a conduit or raceway. Documents Required: Provide copy of State of Colorado Master Plumber and State of Colorado Plumbing Contractor licenses. (10) Electrical Contractor- Class 10 - A license is not required; however, registration with the City of Wheat Ridge through submission of the approved registration and insurance documents is required. This form shall not be used for the purposes of registration. Registration shall authorize the installation of electrical systems, appliances and raceways in accordance with adopted codes and amendments. Documents Required: Provide copy of State of Colorado Master Electrician and State of Colorado Electrical Contractor licenses. (9) Mechanical Contractor - Class 9, shall be authorized to do the following: installation of warm air heating, all ductwork, ventilation and evaporative cooling; the installation of gas piping, burners, venting and controls; and exterior sheet metal; duct isolation; installation of refrigeration systems and appurtenant cooling towers; pipe installation; and low voltage wiring which does not exceed fifty (50) volts and when such wiring is not enclosed in a conduit or raceway. Documents required: Provide copy of ICC Mechanical test or an active Contractors License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (11) Sign Contractor - Class 11, shall be authorized to do the following: fabricating, installing, erection or maintenance of all types of signs. For the purpose of this section, marquees shall not be classified as a sign. Documents required: Provide copies of three active sign contractor licenses from any three municipalities in Colorado. (12) Fire Protection Contractor - Class 12, shall be authorized to do the following: a. Automatic fire sprinkler systems of all types. b. Carbon dioxide systems. C. Standpipe systems and appurtenances. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. (13) Lawn Sprinkler Contractor - Class 13, shall be authorized to do the following: installation of underground lawn sprinkler systems, including tapping the existing water service or main. CRS 12-58-102. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. (14) Roofing Contractor - Class 14, shall be authorized to apply roof covering material to all structures. Documents required: Provide copy of ICC National Roofing test or an active Contractors License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (15) Electrical Signal Contractor - Class 15, shall be authorized to do the following: installation of fire detection, fire alarm, burglar alarm, pneumatic control and all signaling or control systems where the electrical voltage does not exceed fifty (50) volts. Exception: Authorized and franchised public utility companies. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. Date - SIGNAT' E Z 'Z - PRINTED NAME APPROVED BY Chief Building Official 0 � City Of Wh6atp,,Jiddge OMMUNITY DEVELOPMENT 7500 W. 291' Avenue * Wheat Ridge, CO 80033 * O: (303)235-2855 * F: (303)235-2857 Contractor Waiver for Workers' Compensation Insurance I, (print your name), verify that I am the er or partnerof (company name): /J which has no employees and is not required dy the State of Colorado to carry workers' compensation insurance. I further state that if I hire contractors/subcontractors, they are in compliance with the State of Colorado Workers' Compensation insurance requirements and have obtained the required contractor's license from the City of Wheat Ridge. Signature: Date: City of Wheat jd�ge �MEN MUNITY DEVELOP T 7500 W 29th Avenue, Wheat Ridge, CO 80033 P: 303.235.2855 F: 303-237-8929 Email: contractors(a)-ci.wheatridge.co.us LICENSE (office Use): Lic #��. APPLICATION FOR BUILDING CONTRACTORS LICENSE The undersigned affirms that he/she is knowledgeable of the ordinances and regulations of the City of Wheat Ridge relative to building & construction within the City and shall at all times perform in compliance with same as a contractor under the class of license hereby applied for: Lic. Class/Description Fee Lic. Class/Description Fee Class 1 — Unlimited $150.00 See Page 4 for licensing requirements Class 2 — Limited $125.00 See Page 4 for licensing requirements Class 3 — Residential $100.00 See Page 4 for licensing requirements Class 4 — Subcontractors $75.00 All subcontractors or trades not authorized under other license classes Type: Class 8 — Plumbing $100.00 See Page 5 for licensing requirements Class 9 — Mechanical $100.00 See Page 5 for licensing requirements Class 10 — Electrical*DO NOT USE THIS FORM Class 11 —Sign $75.00 Class 12 — Fire Protection $75.00 Class 13 — Lawn Sprinkler $75.00 Class 6 — Homeowner No Fee Class 14 — Roofing $75.00 Testing may be required See Page 6 for licensing requirements Class 6 — Structure Moving $75.00 Class 16 — Electrical Signal $75.00 (Systems < than 50 volts) Class 7 — Demolition $75.00 **USE INK TO COMPLETE THIS FORM** BUSINESS OWNERS; ADDRESS IMS � Serys(-� If corporation, provide EIN 21" N32 -q%0 2 � - PHONE 60�) ' 9 U q - O7i FAX CELL EMAIL CLQ, WIa i Go -VV\ The following documents must accompany this application or it will not be processed: -Copy of corresponding licensing requirement for license class selected -Copy of Insurance certificate per insurance requirements on Page 4 -Form ofPayment( . processed v-ia emai; itliout a credit card authorization form included) *Complete all information on all pages. Sign and date application on Page 6 301 Name(s) c Home Adc Phone nut Signature: Name(s) of owner(s) Home Address Phone number: Signature-.- Name(s) ignature: Name(s) of owner(s Home Address _ Phone number: Signature: Name: U Home Address_ Phone number: Signature: k,r,r 1 I A VA Name: ��O-k'Ao Home Address Phone number: Signature: Name: Home Address_ Phone number: Signature: Name: Home Address Phone number: Signature: *Complete all information on all pages. Sign and date application on Page 6 2 LAWFUL PRESENCE AFFIDAVIT Please provide proof of one of the following: 1. Colorado driver's license or identification card 2. United States military identification or dependent's identification card 3. United States coast guard merchant mariner card 4. Native American tribal document swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): i I am a United States citizen, or I am a Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is frauidulently received. 1 - (-11 0 ( Ax'', 9 5-h6(m Signature U Date S4 n �qm T', �uiVl �a V\ Print Name *Complete all information on all pages. Sign and date application on Page 6 3 Insurance Requirements: Coverage shall include workers compensation and employer's liability in the amount of five hundred thousand dollars ($500,000), General Liability Insurance in the amount of six hundred thousand ($600,000)- general aggregate and three hundred thousand ($300,000) for each occurrence. The City of Wheat Ridge must be listed as the Certificate holder. (Please provide a copy at time of license submittal.) License Classification and Documentation Requirements (a) The various classes of licenses issued under this article and the work authorized to be performed by the holder of the license are as follows: (1) Building Contractor - Class 1, shall be authorized to perform the following: unlimited building, altering, adding to the structural portions of any building, structure or portion thereof of any type, including all concrete, structural steel and iron, and the demolition of all or any part of a building or structure on a site on which he will build new construction, remodel, alter or repair an existing building or structure. Documents required: Provide copy of ICC Class A test or an active Contractors Class A License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (2) Building Contractor - Class 2, shall be limited to Type III, IV or V buildings not exceeding three (3) stories and not used for Educational, Institutional or Hazardous occupancies as defined by the building code. Documents required: Provide copy of ICC Class B test or an active Contractors Class B License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (3) Residential Building Contractor - Class 3, shall be limited to one and two family dwellings and multiple single-family (townhouse) residential structures not exceeding three (3) stories and their accessory structures. Documents required: Provide copy of ICC Class C test or an active Contractors Class C License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (4) Building Contractor — Class 4, shall be authorized to perform work not otherwise authorized under License classes 1-3 and 5-15. This license shall be required of all subcontractors and trades performing work not authorized by other license classes. Documents required: Provide copies of three active subcontractor type licenses with any three municipalities in Colorado. (5) Home Owner Building Contractor - Class 5, shall be issued to an individual who desires to perform work involving construction, alterations or additions including plumbing and mechanical alterations of a single-family dwelling owned by that individual, in which he/she resides and will reside for a period of one year after project completion. This license shall be required when homeowners complying with the above qualifications are performing work which affects the structural sufficiency of the home, or when work is being performed by individuals/contractors other than the owner under the owners supervision. 4 DRIVER LICENSE 1 QUINLAN 2 STEPHSH PATRICK 8 1769 COTTONWOOD ST - 9ROOR1P12LD, CO soon 3 O0S 4a Iss so 8ndors -t- 03t0011sa1 0412412017 4d Customer tdaaww 4b Exp 12 Restrictions 97-022-M1 03106'2022 N --ME -. S DD Pr vloes Type 9 Vehic4a Classifications 17'114414491 A R 16 Sax 1.00 A9 u'g, t 1S Eyes 17 L'f�; Bike 180 611 14"r C I RENEWAL INFORMATION Renewal notices will be e-mailed to e-mail address on ' R@newai information is available at www.donvergov.org/Contractor_Llcensing, ' INSPECTION INFORMATION Inspection requests called in by 12.0^ a. -n °:i.! ei. a• .3 scheduled for the following workir3 ;ry. Please provide the following info srs :.: you call for an inspection: J Permit number J Type of inspection and inspect;cn Automated Inspection Request System: 720-865-2501 Inspections are performed Monday through Friday. Wallet Contractor ID Card: MUST BE KEPT IN YOUR POSSESSION AT ALL TIMES. Cut on outside of line, then fold in half. City and County of Denver City and County of Denver Community Planning and Development IDENTIFICATION CARD 201 W COLFAX AVE DEPT 205 DENVER, COLORADO 80202 License/Registration : LIC245212 No.: DENVER This is to certify that FIREPLACE SOLUTIONS & SERVICES LLC nrw��anur. has been issued a Gas Service license in the City and County of Denver, beginning on 29 March 2018 and ending on 30 Apr 2021, Licenses & Certificates: 720.865.2770 unless license is revoked. Permit Counter: 720.865.2705 Inspection Administration: 720.865.2505 By Authority of the Executive Director of Automated Inspection Request: 720.865.2501 Community Planning and Development ' LIC. 1 Uf(41/100) DAP 2/27/1 S City and County of Denver License/Registration Number. LIC245212 Community Planning and Development Expiration Date: 04/30/2021 www.denvwgov.orglcontractor_licensing Ucense Type: Gas Service ' Issued To: By Community Authority of the Executive Dlractor of - Planninn and DevNooment FIREPLACE SOLUTIONS & SERVICES LLC 1769 COTTONWOOD ST BROOMFIELD, CO 80020 ' Amount FundlOrgiRevenue Code Payment D@te Trans # Status $250.00 R353900'-01010-0141200 03/29/2018 4208211 Paid RENEWAL INFORMATION Renewal notices will be e-mailed to e-mail address on ' R@newai information is available at www.donvergov.org/Contractor_Llcensing, ' INSPECTION INFORMATION Inspection requests called in by 12.0^ a. -n °:i.! ei. a• .3 scheduled for the following workir3 ;ry. Please provide the following info srs :.: you call for an inspection: J Permit number J Type of inspection and inspect;cn Automated Inspection Request System: 720-865-2501 Inspections are performed Monday through Friday. Wallet Contractor ID Card: MUST BE KEPT IN YOUR POSSESSION AT ALL TIMES. Cut on outside of line, then fold in half. City and County of Denver City and County of Denver Community Planning and Development IDENTIFICATION CARD 201 W COLFAX AVE DEPT 205 DENVER, COLORADO 80202 License/Registration : LIC245212 No.: DENVER This is to certify that FIREPLACE SOLUTIONS & SERVICES LLC nrw��anur. has been issued a Gas Service license in the City and County of Denver, beginning on 29 March 2018 and ending on 30 Apr 2021, Licenses & Certificates: 720.865.2770 unless license is revoked. Permit Counter: 720.865.2705 Inspection Administration: 720.865.2505 By Authority of the Executive Director of Automated Inspection Request: 720.865.2501 Community Planning and Development ' LIC. 1 Uf(41/100) DAP 2/27/1 S ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 05/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Scott Bagwin NAME: The Ahbe Group (303) 907-9959 A,c (303) 799-4614 A/cNNo Ext : No : 7167 SAlton Way E-MAIL EACH OCCURRENCE $ 1,000,000 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Scottsdale Insurance Company Centennial CO 80112-2112 INSURED INSURER B: Plnnacol 41190 Fireplace Solutions & Services LLC INSURER C: 1769 Cottonwood St INSURER D: INSURER E: Broomfield CO 80020 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1951096195 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AIJUL INSD 5Ut3R WVD POLICY NUMBER POLICY EFF MMIDDIIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERALLIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,000 (RENTED 100,000 -PREMISES PREMISES Ea occurrence) $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 A CPS3183759 05/07/2019 05/07/2020 NLIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO LOC JECT M PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION PER OTH- B AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) NIA 4203353 07/01/2018 07/01/2019 STATUTE I I ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) I.tKllrlt AIt MULUtK City of Wheat Ridge 7500 W 29th Ave Wheatridge CO 80033 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD (6) Structure Moving Contractor - Class 6, shall authorize moving of any and all types of buildings or structures. The requirement for license applies to any person so performing in the city on public rights-of-way regardless of points of beginning and destination of the performance. (see section 5-42 for insurance and bond requirements) Documents required: Provide copies of three active subcontractor type licenses with any three municipalities in Colorado. (7) Demolition Contractor - Class 7, shall be authorized to perform demolition or wrecking of any building or structure or portion thereof. Documents required: Provide copies of three active subcontractor type licenses with any three municipalities in Colorado. (8) Plumbing Contractor - Class 8, shall be authorized to do the following: installation of all sanitary plumbing and potable water supply piping and appliances connected thereto, and including gas piping and the complete installation of water heaters, the installation of piping for transmission of chemicals and gases; the installation and removal of backflow prevention devices; the installation of gas ranges, gas dryers and gas refrigerators, steam and hot water heating system, process and industrial piping and related appurtenances which shall include the piping used for the transmission of chemicals and gases, the installation of burners, piping and controls utilizing gas, pipe insulation and low voltage wiring which does not exceed fifty (50) volts and when such wiring is not enclosed in a conduit or raceway. Documents Required: Provide copy of State of Colorado Master Plumber and State of Colorado Plumbing Contractor licenses. (10) Electrical Contractor- Class 10 - A license is not required; however, registration with the City of Wheat Ridge through submission of the approved registration and insurance documents is required. This form shall not be used for the purposes of registration. Registration shall authorize the installation of electrical systems, appliances and raceways in accordance with adopted codes and amendments. Documents Required: Provide copy of State of Colorado Master Electrician and State of Colorado Electrical Contractor licenses. (9) Mechanical Contractor - Class 9, shall be authorized to do the following: installation of warm air heating, all ductwork, ventilation and evaporative cooling; the installation of gas piping, burners, venting and controls; and exterior sheet metal; duct isolation; installation of refrigeration systems and appurtenant cooling towers; pipe installation; and low voltage wiring which does not exceed fifty (50) volts and when such wiring is not enclosed in a conduit or raceway. Documents required: Provide copy of ICC Mechanical test or an active Contractors License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (11) Sign Contractor - Class 11, shall be authorized to do the following: fabricating, installing, erection or maintenance of all types of signs. For the purpose of this section, marquees shall not be classified as a sign. Documents required: Provide copies of three active sign contractor licenses from any three municipalities in Colorado. (12) Fire Protection Contractor - Class 12, shall be authorized to do the following: a. Automatic fire sprinkler systems of all types. b. Carbon dioxide systems. C. Standpipe systems and appurtenances. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. (13) Lawn Sprinkler Contractor - Class 13, shall be authorized to do the following: installation of underground lawn sprinkler systems, including tapping the existing water service or main. CRS 12-58-102. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. (14) Roofing Contractor - Class 14, shall be authorized to apply roof covering material to all structures. Documents required: Provide copy of ICC National Roofing test or an active Contractors License from one of the following municipalities: Denver, Aurora, Colorado Springs, Pikes Peak, Fort Collins, Park County, or City of Boulder. Supervisor licenses are not accepted. (15) Electrical Signal Contractor - Class 15, shall be authorized to do the following: installation of fire detection, fire alarm, burglar alarm, pneumatic control and all signaling or control systems where the electrical voltage does not exceed fifty (50) volts. Exception: Authorized and franchised public utility companies. Documents required: Provide copies of three active licenses with any three municipalities in Colorado. Date l l� j ol SIGNAT R PRINTED NAME APPROVED BY Chief Building Official D City of Wheat Ridge Community Development Department 7500 West 29th Avenue Wheat Ridge, CO 80033 Phone (303) 235-2855; Fax (303) 237-8929 Email: contractorsaci.wheatridge.co.us Registration# ❑ New enewal * Please provide a Certificate of Insurance with the City of Wheat Ridge listed as "Certificate Holder" with this application.* ELECTRICAL CONTRACTOR REGISTRATION Ria -zIVED Under the Laws of the State of Colorado ividualq-Name r doing business as i/7 f U.4 Company Name MAY 1 6 Per Address City State Zip Phone # Email/Fax# is hereby registered to perform as an Electrical Contractor in the City of Wheat Ridge, Colorado. State of Colorado Electrical Contractors License Number(#) L' (Attach copy of State Contractor License) State of Colorado Master Electrician Number(#) (Attach copy of Master License) f. 0--, j 41 1 k Electronic Signature I understand that checking this box, that I acknowledge that this constitutes a legal signature (., eom Name(s) of owner(s) % ,a da!L ;i W v 2 ,7 a: Ll�''� Home Address 315 S CIAV 5-C Phone #_ Signature: Name(s) of owner(s) Home Address Phone # Signature: Name(s) of owner(s) Home Address _ Phone# Signature: Name: Home Address 31-6 S CLA4 ST Phone # Signatur Name: Home Address Phone # Signature: Name: Home Address Phone # Signature: Colorado Department of Regulatory Agencies Division of Professions and Occupations Electrical Board Efershan Electric, Inc Electrical Contractor EC.0006913 Number 10/01/2017 Active Issue Date Credential Status 09/30/2020 Expire Date Verify this credential at: www.cotorado.gov/dora/dpo 0,10 Dmsion D o Ronne Hines Credential Hotder Signature Division of Professions and Occupations Electrical Board 4 Bernardino Rodriguez Master Electrician ME.0028949 10/01/2017 Number Issue Date Active 09/30/2020 Credential Status Expire Date Verify this credential at: www.cotorado.gov/dora/dpo Division Directo . Ronne Hines Credential Holder SignatuCe AC4ORb1r CERTIFICATE OF LIABILITY INSURANCE DAi�z' ei THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER Partners Risk Services, LLC 10692 Medlock Bridge Road Suite 200 Johns Creek GA 30097 Rhonda Neubert PHONE(770) 609-2700 F ; 1770)"9-2749 Aff- E s: rneubert8partnerors.Cam ADDRES INSURERM AFFORDING COVERAGE NAIc r INSURERA:Ohio Securi Insurance Conpany 24082 INSURED Eferahan Electric, Inc. 315 S. Clay Street Denver CO 80219 INsume:Hartford Accident and Indemnity ins Co. 22357 INSURER C: 94SURERD: N SURER E . DrsuRERF: COVERAGES CERTIFICATE NIIMRFR:CL1912817188 RFvlelnru wlul2cQ• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR TYPE OF INSURANCE OL PICYNUMem Y F POUF EXP La1R3 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OX OCCUREMI ET.92058551945 1/26/2019 1/26/2020 EACH OCCURRENCE S 1,000,000 o oe S 300,000 MED EXP aim prion) S 15,000 PERSONAL SADVINJURY $ 1,000,000 GM AGGREGATE LIMIT APPLIES PER X POLICY ❑ JECT F� LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP)OPAGG S 2,000,000 S A AUTOMOBILE LIABILITY X ANY AUTO ALLOSONMEO A�� LED S NON -OWNED HIRED AUTOAUTOS eA35a551965 1/26/2019 1/26I202C COMBIN OSWt LE LwIT S 1,000,000 Me BODILY INJURY (P4r Perow) S oca BODILY INJURY (Pet dW) S R RTY DAMAGE S r otoiaent U,y44,yed vmWn cwabimd ,M* f 1,000,000 UMBRELLA LIAB EXCE33LIAB HCLAIMS-MADE OCCUR 1 1 EACH OCCURRENCE S AGGREGATE S OED I I RETENTIONS S H WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXEg1TWE OFFICERtMEMBER EXCLUDED?Y (MaARlery In NH) Nysa dewiba Under DESSCitIPTt OF OPERATIONS below NIA 20MBCAI366S 6/10/201® 6/10/2019 X TA EL EACH ACCIDENT S 5001000 E L DISEASE - EA EMPLOYEES 500, 000 E L OISEASE •POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AdURUonal RemmMe SdrdWq wAy be *KwhW N mere epme Mr re"Ired) City of Wheatridge Community Development Department 7500 W 29th Ave. Wheat Ridge, CO 80033 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Thompson/RHs'N:A All rights reserved ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 rm sor. Lev_ Contractors, Inc. 10981 Brighton Rd, Henderson CO 80640 (303) 281-4900 Fax (303) 281-1120 May 6, 2019 City of Wheat Ridge Building and Inspection Services Division 7500 W. 29`x' Avenue Wheat Ridge, CO 80033 Re: Contractor License — ExcavatioEl #170099 To Whom it May Concern, Below is a list of persons able to pull permits - Bill King - Tom Mari - Jorge Diosdado - Lora Garcia ACERTIFICATE OF LIABILITY INSURANCE °111 1 6�2z/2ols THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Debbie Smith, CIC Moody Insurance Agency, Inc. PHO,Nn o, Ext): (303)824-6600 FAX No): (303)370-0118 8055 East Tufts Avenue aDORless:debbie.smith@moodyins.com Suite 1000 INSURER(S) AFFORDING COVERAGE NAIC# Denver CO 80237 INSURERA:BITCO General Insurance Corporation 20095 INSURED INSURERB:Pinnacol Assurance 41190 Levi Contractors, Inc. INSURER C: 10981 Brighton Rd INSURER D: INSURER E Henderson CO 80640 INSURER F: COVERAGES CERTIFICATE NUMBER:18/19 No Forms REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR SUBR FEE POLICY EXP TYPE OF INSURANCE INAl POLICY NUMBER (MMDDPOLICY LTR YYYY MM/DDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000, 000 A CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) S 100,000 CLP3669904 7/1/2018 7/1/2019 MED EXP (Any one person) $ 10,000 PERSONAL B ADV INJURY S 1,000,000 GENT. AGGREGATE LIMIT APPLIES PER. GENERAL. AGGREGATE S 2,000, 000 X POLICY PRO ECT LOC PRODUCTS - COMP/OP AGO S 2, 000, 000 OTHER. Pollution Liability -Worksite S 1,000, 000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 5 1, 000, 000 X ANY AUTO BODILY INJURY (Per person) S A ALL OWNED SCHEDULED CAP3669905 7/1/2018 7/1/2019 AUTOS _._ AUTOS BODILY INJURY (Per accident) S NON -OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS (Per accident) Uninsured motorist combined S 1,000,000 X UMBRELLA LAB XOCCUR EACH OCCURRENCE S 4,000,000 A EXCESS LAB CLAIMS -MADE AGGREGATE S 4,000,000 DED X RETENTION $ 10,000 CUP2814430 7/1/2018 7/1/2019 S WORKERS COMPENSATION X PER OTH- AND EMPLOYERS LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? N / A B (Mandatory in NH) 1964210 7/1/2018 7/1/2019 E . DISEASE - EA EMPLOYEE 5 1,000,000 If yes describe under DESCRIPTION OF OPERA IONS below E . DISEASE - POLICY LIMIT S 1,000, 000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) l,li I IrII.A 1 C MULL)l I.AINI.CLLA I i City of Wheat Ridge 7500 W. 29th Avenue Wheat Ridge, CO 80033 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE D Smith, CIC/HAZPAL C - © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) Name(s) of owner(s Home Address Phone # Signature: Name(s) of owner(s Home Address Phone # Signature: Name(s) of owner(s Home Address _ Phone# Signature: Name:(, Home A9K Phone 4-) Signature: Name: .12 Home Ad Ph( Sig Nat Hot Ph( Sig dress ACOR" CERTIFICATE OF LIABILITY INSURANCE `,�./ DATE (MM/2019 Y) F 04/25/2019 - THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Janelle Goeden NAME: Platinum Insurance Group PHONEo (605) 271-4446 FAX (866) 615-5716 A/C NExtl: A/C, No 4009 49th Street, Suite 103 E-MAIL I @pnumins anelle latir com ADDRESS: 9 p' INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Technology Insurance Cc 42376 Sioux Falls SD 57106 INSURED INSURER B: ' 888 Heating, Inc /�/�' / INSURER C: 7338 Alton Way 16h / J (// INSURER D INSURER E: Centennial CO 80112 INSURER F: COVERAGES CERTIFICATE NUMBER: zvl`,1-zuzu cen RFVISIAN NIIMRFR• THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEAUULbUBK INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY —1_7DAMAGE CLAIMS -MADE OCCUR EACH OCCURRENCE $ TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GEN'LAGGREGATE LIMITAPPLIES PER: PRI—F—] LOC POLICY GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ ANYAUTO VN ED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per accident UMBRELLALIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION X A AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ❑ N /A TWC3789874 05/08/2019 05/0$/2020 STATUTE EORH EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) yes, describe under D DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those ususal to insured's operations MULUCI[ City of Wheat Ridge 7500 W 29th Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Wheat Ridge CO 800331!P,G,c ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ~I City of WheatM e COMMUNITY DEVELOPMENT City of Wheat Ridge Municipal Building February 18, 2009 Keith Dillion Outdoor Ads, Inc. P.O. Box 1078 Denver, CO 80201-1078 Dear Mr. Dillion, 7160 3901 9844 2844 7498 i II You hold the revocable miscellaneous building permit No. 080622 for courtesy benches pursuant to section 21-142 of the Wheat Ridge Code of Laws (the "Code"). Earlier this month, you were contacted by Mr. Tim Paranto, Director of Public Works, regarding potential changes to the courtesy bus bench program that were being considered by City Council and that those changes might cause the City to need to revoke your current permit. This letter is to inform you that the permit listed above is hereby REVOKED effective immediately. Pursuant to Code section 21-149(b), the City may revoke such permits "at any time without cause." You will not be permitted to reapply for this permit. Pursuant to Code section 20-143, you are not entitled to a rebate or refund of any permit fees due to such revocation. The City Council has enacted changes to the City Code that will change the courtesy bus bench program. While you will be invited to provide a proposal to supply benches under the new program, you should be aware that the new program will require benches substantially different from the benches you are currently using in Wheat Ridge. You have thirty (30) from today to remove the courtesy benches associated with the permit listed above. If you fail to remove those benches within that time frame, the City shall have the immediate right, pursuant to Code section 21-150, to have the benches removed and charge the expenses for such removal to you. Prior to expiration of the thirty days (30), the City will entertain a written request to leave some or all of the existing benches in place until a vendor is selected under the new program. If you have any questions, please contact Tim Paranto, Director of Public Works, at 303-235- 2860. Mr. Paranto will be responsible for the operation of the new courtesy bus bench program. ne, AICP Development Director 7500 W. 29" Ave. Wheat Ridge, CO 80033-8001 P: 303.235.2846 F: 303.235.2857 SENT BY CERTIFIED MAIL www.ci.wheatridge.co.us February 24, 2009 Ken Johnstone, AICP Community Development Director City of Wheat Ridge 7500 West 29 h Avenue Wheat Ridge, CO 80215 Dear Mr. Johnstone, Thank you for the letter informing us on the city's upcoming plans to change the courtesy bench program. I would like to request that the City of Wheat Ridge gives Outdoor Ads, Inc. permission to leave all of their existing benches in place until the new benches are installed. We feel this extension would be of great benefit to the City and its citizens. This extension would make sure that transit riders won't be without a place to sit while waiting for the bus during this transition. Once the new benches are ready to be put in Outdoor Ads, Inc. would coordinate the removal of the current benches with the installation of the new. This will ensure there's no lapse that leaves bus users without a place to sit and we'll make sure our current benches are removed so they are not there along with the new ones. Please let me know if the city approves this request for this extension as soon as you have a chance. I look forward to receiving the RFP for the new bench program and having the opportunity to continue to provide Wheat Ridge with bus benches for years to come. If you have any questions or need anything please feel free to contact me at 303-292-1802 or by e-mail at KDillion@OutdoorAdsOnline.com. Thank you, Keith Dillion President B 2. Article Number 111 1111 Jill Jill 1111 AROcave,, 60 3901 9844 2844 7498 D. fives E 71 3. ServiceType CERTIFIEDMA'IL 4. Restricted Delivery? (Bdra Fee) Dyes 1. Article Addressed to: Keith Dillion Outdoor Ads, Inc. P.O. Box 1078 Denver, CO 80201-1078 PS Form 3811, July 2001 Domestic Return Receipt i t e^arty) B. Date of Delivery J ~ ❑A9ent ❑ Addres mt from item 1? ❑ Yes Iress below: ❑ No o f