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CITY OF ORONO <br />(612) 473-7357 <br />2750 Kelley Parkway, P-0. Box 60 <br />Crystal Bay, MN 55323 <br />^ lirtme fee bond, Cenificate of Insurance and evidence of MPCA <br />All questions must be answered. subject to a ten (10) day approval period. <br />Certificatioa must be attached. All appucau^ <br />1. <br />2. <br />j. <br />4. <br />/ / U_______________________Business or trade name____i/C I r~ <br />Business address /Q ---------------------- ^ uip) <br />Business phone <br />(strecU <br />- I s~^1 <br />(city) <br />Residence phone _ <br />Name of applicant or company rep^entative(s) holding MPCA certification <br />5. <br />6. <br />Type of certiftcation held: JJnsuller JC Pumper Expiration date: <br />Have you ever held a Septic System Installer license in Orono before? <br />Most recent year ^----------- <br />Have you ever had a license revoked? J>£— WTien? -------------------------- <br />Where? <br />No <br />8. <br />9. <br />CITY CF_ <br />ri^niYCE CFFICE <br />131:500000 <br />I *17 rryVJL cull <br />Do you do Municipal Sewer hook-ups? Yes _)0 — <br />Do you pump out septic tanks? Yes — No <br />SUBMITTALS REQUIRED^ <br />^ 1. $50.00 License application fee. ritv nf Orono as obli«^ee. The State Plumbers <br />2. $2,000.00 license and penmtbond nai^ City of Orono as obligee. <br />------- Bond will not be accepted. /s<r>, )) ) 9CT <br />$50-100-300,000 minimum C^ificate of Insurance. <br />~ 4 Copy of current MPCA Certificawc. <br />i-Vi».‘Vt vv <br />lFOCK Jk........kEiEIPi-ii':^{^.ruU, <br />t'nni tjtif / t ? <br />:i A/r^ \ <br />^opy <br />licenses will not be PROCESSED UNTIL ALL ITEMS ARE SUBMIITED <br />Lis. person^ oUtcr dtan applicant who are audtorized by you to apply for permits underyo^ <br />and the Ordinances of the City of Orono. <br />. t/.U^ ' <br />Date O-'- <br />^ _f * 1CITY <br />USE <br />ONLY <br />Reason for denial: ______ <br />City Council Action: Date <br />Date license mailed_____ <br />Approved