Laserfiche WebLink
l )`,* of Ueet at: 1))5 Provn Pned S..1h <br />CITY of ORONO SEPTIC 51'STE47 INSTALLERS <br />.t,u mq Haase..: P. a. u.. id <br />c11.1a1 my, Me 55321 LICENSE APPLICATION <br />Phone:.))-2)5) <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 `his application. All appli- <br />cations are subject to a tennnl1 �)10) day approval period. <br />1. Business or trade n . .B'�i��__ �:_ .es_ <br />2. Business address 7/ 1. O J<_A_C ' � ��� �F" <br />3. Business phone U 77-$74.#9 Residence phone'f77-3Lr19 <br />4. Name of applicant or company representative holdina MPCA certifi- <br />cation <br />5. Type of certification held: XInstaller _Pumper <br />_Site evaluator _System designer �/^1 <br />Is this a Provisional Certificate Sit—CERTIFIC�ATTEE NO._�. <br />6. If no Certificate is held, provide evidenceCof attendar;;,e {o e <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?,L4Z Most recent year 1,7 1V <br />B. Have you ever had a license revoked? Y�Whe n?-Where ? <br />I TTALS REQUIRED: <br />$25.00 license application fee. <br />04- _2. $2.000.00 license and permit bond naming City of Orono as <br />obligee. The State Plumbers Bond will not be accepted. <br />3. $10-50-100,000 minimum Certificate of Insurance. <br />04. Copy of current MPCA Certificate or evidence of attendance at <br />j3.�On -Site Sewage Treatment Workshop held immediately prior to <br />current construction season. <br />8 LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by you to apply <br />for permits under your license <br />The uedQf$iy..d Mreny ..k.. e)plleellon to the City of Omn.. Mlnneeot., for Ile. . a. In. t.II ..4 <br />repair ..plic .Yet..., no pmp -it Septic tenet. subject to the I... of the dtale .f Minnuol. <br />.nd the Ordin.ne.. of the City of teen.. <br />Date- 7- PY- Applicants signature <br />saaff reeo:oene. W.W.- <br />9 ..... for eenia l: _ <br />City C... eil dcum: wie: dvprorea:_ pniee: <br />Chile lies ".-- <br />OFFICE USE ONLY <br />