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(1,ITY ui' 0IMN0 <br />All quee.tionn must be annwercd. License fez, bond, certI "I tc of _ <br />insurance, and evidence of MPCA Certification or Home Sew�.y 1' _1 <br />menC workshop attendance must accompany this application. {-yt�{ <br />cations are subject to a ten (10) day approval period. <br />1. Business or trade namej-(tZv(Tj <br />2. Business addressohn 13A n-V . Yh.. ri S.•?C..3 <br />3. Business phc:;c±2 - 311241 Residence hone <br />P /7.z-:3,5:2 <br />3 <br />E <br />Name or anr./ 1,cr:::;. or, coran+•ly yen:'c:-cs:a:i•:c !loldir,g ,a C;:. ceu:ifi- <br />ca.ic:-..1�_rS ---- <br />Type of certification held: (Installer _Pumper <br />_Site evaluator _system designer <br />Is this a Provisional Certificate? CERTIFICATE NO. <br />If no Certificate is held, provide evidence of attendance at one <br />Of the On -Site Sewage Treatment Workshops held immediately prior <br />to the current construction seaso::.l,; eh* to t;+,✓rK ite'o i ) 118M <br />( M'r se+"r h1 nq �', <br />Have you ever held a septic System Installer license in Orono <br />before? FV �' Most recent year$nhy <br />Have you ever had a license revc!:ed-! NC1V.hen? Where? <br />SUB!•71TTi.Ls REQUIRED: <br />r K �1. $25.00 license application fee. <br />2. $2 000.00 license and permit bond naming City of Orono as <br />obligee. The State Plumbers Bond will not be accepted.&-A7Av.g�-vt(j <br />On _3. $10-50-100,000 minimum Certificate of Insurance. <br />bK 4. Copy of current MPCA Certificate or evidence of attendance at <br />On -Site Sewage Treatment workshop held immedi: ay prior to <br />current construction season. <br />LICENSES WILL 140T BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by you to apply <br />for permits under your license Fu r„4i 1Aw { H1 yF•- <br />Tn. untveltna< nettGy ,uSe..pDlio Uen to lM city a! O.ono. Xlnnewu, lot I{tanaa t. Inual .nt <br />r. D.tr .apUt apte.a, .nC/ot paM eat .opt le unb. .anl.tt to tM 1... 0 tna Sut. of ninna.ou .na the O, Oinnnert of th ctty at 0'... [ Date t. _ yj� Applicants signature r <br />w.tt t.coa„t ne,t ia:, nDDto..l .� oeni. [:_ o <br />r<.aan tot acn;.l: .. <br />S- <br />011 i(Ci O`'i' <br />