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CITY of Q➢RONO CrY.WIAr.MinewAnC.dZ, <br />BUILDING a ZMING - 4730157 <br />ASSESSING <br />SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />All questions must be answered. License fee, Donor certificate <br />of insurance, and evidence of MPCA Certification or Home Sewage <br />Treatment Workshop attendence must accompany this application. <br />All applications are subject to a ten (10) day approval period. <br />1. Business or trade name IA l/erN A'" - `ti Sw-S X_' <br />2. Business address 1, io !' .0F ?' � -- <br />3. Business phone -/7f- > 17 Residence phone It <br />D% <br />4. Nam of applicant o company representative holding Mf!'1>1IM.i OF <br />certification �I1 t ll„-///r 13115000M <br />01 UN <br />S. Type of certification held: Installer _r_ Per. R <br />Site evaluator System designer <br />Is this a Provisions Certificate? Certif icateef"1PTflIAT� <br />6. If no Certificate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops held immediate <br />prior to the current construction season. <br />7. Have you ever held a Septic System Installer license in <br />Oronc before? _g5 Most recent year <br />8. Have you ever had a lic.:nse revoked? U , When? <br />Where? _ <br />4. Do you do Municipal Sewer hook -opal Yes <br />_4L No _ <br />SUBMITTALS REQUIRED: <br />,X1. $25.0( license application fee. <br />2. $2000.00 license and pernit bond naming City of Orono as <br />obligee. The State Plumbers Bond will not be accepted. <br />a/ 3. $10-50-100,000 minimum Certificate of Insurance. <br />,i C. Copy of current MICA Certificate or evidence of attendance <br />at On -Site Sewage Treatment Workshop held immediately <br />prior to current construction season. <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED. <br />YOU <br />ill <br />List persons other than applicant who are authorized Oy you to <br />apply for permits under your license <br />The undersigned hereby makes application to the City of <br />Orono, Minnesota, for license to install and repair septic <br />systems, and/or pump out septic tanks, subject to the laws <br />of the State of Minnesota and the Ordinances of the City of <br />Orono. — <br />Date iI')I Applicants Signature <br />Staff recommendation Approval , Denial Date <br />CITY Reason for denial, <br />USE City Council Action Date Approved _ Den 0 <br />ONLY Date license mailed _ <br />