Instructions:  If application is made on behalf of a corporation, such information should be furnished and the other information shall refer to the operating manager of the business.

 

City of Plattsburgh

Clinton County, New York

Application for License to Collect, Remove, and/or Dispose of Refuse in the City of Plattsburgh, New York as per Ordinance Dated 12/22/82 and Amended 1/20/83.

Application is hereby made for a License to Collect, Remove, and/or Dispose of Refuse in the City of Plattsburgh, New York as per Above Mentioned Ordinance or any Amendments Thereof.

 

 

Corporation Name:      

Name of Individual:     Date of Birth:    Sex:

Social Security Number:Height:Weight:Eye Color:   Current Address:

Have you Ever Been Convicted of a Crime? Yes  No

If Yes, What Crime(s), Date(s), Place(s) of Conviction:

Crime(s)                                Date(s)                                Place(s)

How Many Vehicles Do You Use? 

Do You Hold a Valid N.Y.S. License as per Section 501 of the Vehicle and Traffic Laws of the State of New York: 

                                                                                                                                                                 Yes No

Has it Ever Been Suspended or Revoked? Yes No, If yes, Give Date, Why, and Where: 

This application is for (make of vehicle):

Year of Vehicle:                     Vehicle Identification Number (VIN):

Weight Capacity:                     License Number: 

Is the Vehicle Properly Identified as per Ordinance?  Yes No

Certificate of Insurance Provided:  Naming City of Plattsburgh as Additional Insured

Public Liability in the Amount of $300,000: [Yes No] for Damages to Property from any One Accident or Incident (Combined Single Limit for Personal Injury or Death or Property Damage)

License Fee:  $100.00 per Vehicle per Calendar Year.

 

I understand that, if I violate any of the provisions of the ordinance , a copy of which I have read or purchased, that I shall be fined a fee of not less than $5.00, nor more than $200.00 for each offense, and a separate offense shall be deemed committed on each day during or on which a violation occurs or continues.

 

                                                                                                            ____________________________________

                                                                                                                    Signature of Applicant

                                      Insurance Certificate Reviewed and Accepted: ___________________________________

 

                                    Permission to Issue License Granted By:         ____________________________________

                                                                                                                                    City Clerk

License Issued By: _____________________________   Date: _____________________