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CITY of ORONO cMW1 ear. Min,.Mn lam <br />BUILDING A ZONING-tl54)57 V - III <br />ASSFSSING <br />All questions must be answered. License fee, d, certifica <br />of insurance, and evidence of MPCA Cert ificat' me Sewage <br />Treatment workshop attendence must accompany <br />All appli^ations are subject to a ten (10) day approval period. <br />1. Business or trade name 2e {c-�.=�rd 5�:.,,:r s.•. r•ac <br />2. <br />Business <br />address <br />I11r1c <br />2777, .iu �_ <br />3. <br />Business <br />phone <br />Residence <br />phone <br />4. Name of applicant or company representative holding MPCA <br />certification R 'cl and .✓ 'a I5 <br />5. Type of certification held: Installer � Pumper <br />Site evaluator System designer <br />Is this a Provisional —certificate? A,,Certificate No.139� <br />6. If no Certificate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops held immlediatel <br />prior to the current construction season. <br />7. Have you ever held a Septic System Installer license in <br />Orono before? l� � Most recent year <br />S. Have you ever had a license revoked? `v, When? <br />Where? _ <br />4. Do you do municipal Sewer hook-ups? YesNo <br />SUBMITTALS REQUIREDt `rnu- _-•�,. y+� <br />L� 1. $25.00 license application fee. <br />2. $2000.00 license and permit bond naming City of Orono as 1 <br />obligee. The State Plumbers Bond will not be accepted. <br />Je 3. $10-50-100,000 minimum Certificate of Insurance. <br />j- 4. Copy of current MPCA Certificate or evidence of attendance I <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 />List persons other than applicant who are authorized by 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. //�� I <br />Date 7/,5/6J Applicants Signature C�.�,.,�G.:,./,�.<�`•-+I <br />Staff recommendation 'Approval % Denial Date <br />CITY Reason for denial, <br />USE city Council Action Date Approve _ DenLcT <br />ONLY Date license mailed <br />