EXCAVATORS & GRADING OF LAND SUPPLEMENTAL APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

Complete this application in addition to the General Liability Application

1. How long have you been in business?      Full-Time    Part-Time

2.
Employee Data        
 
Number
Annual Payroll
Owner(s) only
$
Full-time
$
Part-time
$
Leased or Subcontracted
Number
Annual Cost
Leased Employees
$
Independent Contractors
$

3. Projected annual sales: $

4. Operations:
Yes    No Does applicant or their subcontractors use explosives? If so, describe:
Yes    No Does applicant make a thorough study of the subsurface, including identification of existing utility pipes and lines, prior to any digging?
Yes    No Is all self-propelled mobile equipment transported to job sites by trailer?
Yes    No If shoring is required on a job, does applicant use OSHA approved equipment and techniques?
Yes    No Does applicant have sufficient signs, barricades, and fences to keep non-employees at a safe distance from job sites and equipment?      Equipment is owned or rented.  If rented, attach a copy of the certificate of insurance from the rental company.
Yes    No Does applicant do off-season plowing? If yes, annual receipts from snow plowing: $
What do they plow for?
Yes    No Any underground tanks, petroleum products, LPG, flammable liquids, ammunition or explosives stored on premises? If so, type and quantity stored:
Yes    No Any equipment loaned, leased or rented to others?
If so, describe type of equipment and annual rental receipts:
Yes    No Does applicant subcontract work? If so, state type of work:
Are certificates of insurance obtained from subcontractors? Yes No
Yes    No Any work completed involving underground storage tank removal; tunneling; earthen dam construction; river channeling or rechanneling; mining; work on landfills; street or road construction; or water main, sewer or pipeline construction? If yes, describe:
Yes    No Site preparation for residential housing?

 

Application Completed By:     Date: