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Y of - <br />� . �.. ... .., <br />L1CL,7S:> APPLICATION <br />All y110%1110n�. <br />!..e ;e answered. <br />License fee, <br />bond, certificate of <br />insurance, <br />osu eClemlce <br />of APCA Cc rtif ieaLion <br />or Home Sewage Treat- <br />i <br />ment Workshop <br />attendance <br />must accompany this <br />application. All appli- <br />cations are <br />subject to a <br />ten (10) day approval <br />period. <br />1. Business or trade name fZ 4'1xS �l, XRC <br />2. Business address�Aiiy l//f <br />3. business phone y7s-4'3G/ Residence phroe SM'+w <br />4. Na-e cf :4icr:nt or company rcprescntaLivc holdino HPCi. ccrti'i- <br />5. Type of certification held: -el-li'nstaller _Pumper <br />_Site evaluator —System designer <br />Is this a Provisional Certificate?A10 CERTIFICATE NO. 00 "I <br />6. If no Certificate is held, provide evidence of attendance at one <br />of the On -Site Sewage Treatment Nor F.shcps held ir.:.-,ediately prior <br />to the current construction season. <br />7. Have you ever held a Septic System, Installer license in Orono <br />before, A6gr Most recent year /9VI <br />8. Have you ever had a license revc):cd?,&/fi when- Where? <br />SUBMITTALS REQUIRED: <br />_1. $25.00 license application fee. <br />_2. $2.000.00 license and permit bond naming City of Orono as <br />obl.gcc. The State Plumbers Bond will not be accepted. <br />_3. $10-50-100,000 minimum Certificate of Insurance. <br />_4. Copy of current MPCA Certificate or evidence of attendance at <br />On -Site Sewage Treatment Workshop held immediately prior to <br />current construction season. <br />LICENSES WILL NOT BE PROCESSED U14TIL ALL ITEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by you to apply <br />for permits under your license _r <br />Th. unae nignv0 by rcLy viva 'PP" '"" le the rill of Omne, elnnoeb. r llr.... 1. <br />'rp.lr qpt fa ryne.., .nA /or'.T wa .epll. 1. 11. ..bj.c, le the Lv. (' !uN Of alnnv am,: <br />.nC the OrUn..oe of lhr ell' e( 0'... <br />Date Applicants signature <br />tt.f( weon�nln lr.n—eppw.ai� 4nb1:� Mls — ��� <br />•u wn fer Le ni.l: • <br />Uly r.uM ll M11— U.I. pf.,neN:_— p ."d: I <br />U.0 3ri n.. ht OFFICE USE 0::1.'i <br />