Building Official Individual Personal License Form

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Minnesota Department of Labor and Industry

Construction Codes and Licensing Division

CCLD Licensing / Building Officials

443 Lafayette Road North

St. Paul, MN 55155-0220

Mailing Address:

P.O. Box 64220

BUILDING OFFICIAL

St. Paul, MN 55164-0220

Individual Personal License

Email:

dli.license@state.mn.us

Website:

Phone: (651) 284-5031

LICENSE FEE IS NONREFUNDABLE

SPACE IN BOX FOR OFFICE USE ONLY

CASH IS NOT ACCEPTED BY MAIL OR WALK-IN

Licenses may only be renewed 60 days prior to expiration date.

Account Number

STK

632404

B42BOCERT

Check Number

Amount Paid

New

Renewal

Late Renewal*

Building Official Limited (LB)

$30.00

$35.00

$50.00

PCK

CCK

DLI Deposit Date

Accessibility Specialist (AS)

$30.00

$35.00

$50.00

Certified Building Official (BO)

$60.00

$65.00

$95.00

NOTICE: Pursuant to Minnesota

Statute § 604.113, checks returned

* A late fee is due if the renewal is received by DLI after

for nonpayment will be charged a

the expiration date per Minn. Stat. § 326B.092; subd. 3

$30 service charge and may subject

the issuer to additional civil penalties.

LICENSE NUMBER:

clearly

RINT

NK OR TYPE

AKE A COPY OF THIS FORM FOR YOUR RECORDS

The information you as an individual provide in this application will be used by Department of Labor & Industry staff members to determine if you meet the

Department’s registration requirements. Minnesota Statute § 270C.72, Subd. 4, requires you to provide your social security number on this application. The other

information is being requested for purposes of processing your application. With the exception of your Social Security, you are not legally required to supply the

requested data on this application; however, failure to provide the requested information may delay the processing of your application or result in the denial of the

same. Except for your name and designated address, the information you provide on this application is private data while the application is pending. Disclosure of

this information to others may occur as authorized or required by law, including but not limited to the Attorney General’s Office, the Department of Revenue, the

Department of Human Services, upon court order, and/or for the purpose of verification and investigation. Once you are registered, the information you provide,

other than your Social Security Number and non-designated address, becomes public data and may be released to anyone upon request.

Your renewal can be processed today if you do it online at

https://secure.doli.state.mn.us/license/intro.aspx

SOCIAL SECURITY NUMBER

DATE OF BIRTH (MM/DD/YYYY)

AREA CODE & PHONE NUMBER

E-MAIL ADDRESS

LEGAL LAST NAME

SUFFIX (JR, SR, II, III) LEGAL FIRST NAME

LEGAL MIDDLE NAME

RESIDENTIAL ADDRESS

PUBLIC MAILING ADDRESS (if different from residential address)