DATE:

NAME OF APPLICANT:

ADDRESS:

TELEPHONE NUMBER:

TYPE OF WORK TO BE PERFORMED:  REMOVAL OF TREES             REMOVAL OF STUMPS

                                                                     TRIMMING OF TREES

LOCATION OF WORK:      

CERTIFICATE OF INSURANCE:

1)  All certificates must be on the comprehensive accord form naming the City of Plattsburgh as additional insured.  Must have thirty (30) days written notice of cancellation.

2) General Liability:

    Premises - Operations            BI/PD    $500,000,        C.S.L./$1,000,000,  Aggregate.

3)Workers Compensation and Disability Benefits.

LICENSE FEE:   $150.00 per year from JANUARY of each year to DECEMBER of such year (not pro-rated).

It is my understanding that if I violate any of the provisions of the Ordinance, a copy of which I received, that I shall be fines not less than $25.00 nor more than $100.00 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: 

LICENSE ISSUED BY:    DATE: