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CITI' of JRONO <br />LICENSE Ai'DiACM1'I0L' <br />rh��•e . nn bS: <br />All questions must be answered. License fee, bond, certificate of <br />insurance, and evidence of MPCA Certification or Home Sewage Treat- <br />ment Workshop attendance must accompany this application. All appli- <br />cations are subiect to a ten (10) day approval period. <br />1. Business or trade name <br />2. Business address/Y/�D <br />3. Business phone Sig/�-tld ?x- Residence phone <br />4. Name cf icant or company representative holding MPCA. ecrtifi- <br />catic: appli,t 0( C.4 e, r� iuC r'L s <br />5. Type of certification held: XInstaller _Pumper <br />xSite evaluatorSystem designer <br />Is this a Provisional Certificate?�(J CERTIFICATE NO.00 .d - <br />6. 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 season. <br />7. Have you ever held a Septic System installer license in Orono <br />before?, e 9 Most recent year / rj y f/ <br />S. Have you ever had a license revoked? �rwhen?- r Nhee? <br />SUBMITTitLS REQUIRED: -- s*/ti <br />Z1. $25.00 license application fee. P'j. r'e U'.L—Pfnoge <br />12. $2,000.00 license and permit bond naming City of Orono as <br />obligee. The State Plumbers Bond will sot be accepted. p¢G�c —1 <br />✓ 3. $10-50-100,000 minimum Certificate of Insurance. P' 0 <br />—LL�4. Copy of current MPCA Certificate or evidence of attendant at <br />On -Site Sewage Treatment workshop held immediately prior to <br />current construction season. <br />LICE14SES 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 %%/D it e, <br />the undlt.lsned h,,,b, hetet appllv.tlon 10 the City of tho.c. elnne aeu, fur )lwnte to }ntt.11 enG Npel! le pt is ayttot, ..dyer pulp out teptie tint., tub)ect t0 the )out of the Stott of nMna tau .nd the dt di...... 01 the City of OmnO. <br />O <br />Date J 2 _ Applicants signature <br />Stiff rlCotnenla U un App, ovll <br />p.ton lo, Grn,al:_ <br />Denial:_ "t<: <br />j <br />__._ el ly t..a J.__ Non l•i:__ <br />OFFICE USE <br />