08/20
APPLICATION FOR REMOVAL OF TREES AND STUMPS AND THE TRIMMING OF
TREES IN THE CITY OF PLATTSBURGH, NEW YORK
Date:
Name of Applicant/Company:
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 30 days written notice of cancellation.
2. GENERAL LIABILITY:
a. PREMISES-OPERATIONS BI/PD $1,000,000. C.S.L. $2,000,000 AGGREGATE.
3. WORKER’S COMPENSATION AND DISABILITY BENEFITS.
**License Fee: $260.00/year from January-December of Each year (not pro-rated)**
It i
s my understanding if I violate any of the provisions of the Ordinance, a copy of which I have received, that I
shall be fined 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
Insu
rance Certificate Reviewed and Accepted: _____________________________________________________________
Permission to Issue License Granted By: ___________________________________________________________________
License Issue By: __________________________________ Date: _________________________________________
