620 BAYWAY BLVDa CITY OF CLEARWATER - PLANNING & DEVELOPMENT SERVICES
TREE REMOVAL PERMIT
NAME OF OWNER
OWNER'S ADDRESS 7,1021,K'06' C2`'S1 6 F� _3ei6 1
PHONE 5_/i -pyl�SZ
SITE ADDRESS d G' (yoV r3cG
LOCATION OF TREE(S) ON L
SPECIES AND NUMBER OF TREE(S) t3
TO APPLICANT: A non - refundable fee of $15.00 for up to five trees to
be removed, plus $3.00 for every tree above 5 to be
removed is required.
REASON FOR REMOVAL:
• Construction
• Permit #
-See "A" below
• Hazardous
• Declining
• Dead
• Other (Specify)
Fee Recd
Receipt #
Date
S
A) CONSTRUCTION
1. For new construction, additions or other modifications of a property which involve the removal of a protected tree(s),
a site plan is required. This site plan must have a minimum scale of 1 " =20' for single family lots, or 1 " =50' for all others. The
site plan must include:
a. Major Changes of Grade f. Proposed Number of Parking Spaces j. All Protected Trees Including:
b. Structure Locations g. Proposed Underground Utilities (i.) Diameter of 4.5' above grade (DBH)
c, Driveways and Walks h. Zoning Setbacks (ii.) Surveyed Location
d. Parking Arrangement I. All easements and Rights -of -Way (iii.) Species
e. Required Number of Parking Spaces (iv.) Diseased or Insect Infested Trees
k. Tree Barricade Detail & Locations
2. Protective barriers are required around all trees remaining on site during construction. These barricades must remain
intact during construction. The barriers must meet City Specifications.
B) REPLACEMENTS
1. Tree replacement minimum standards: 12' overall height, 4" caliper, Florida Grade #1. See inspectors note below to
determine the number of replacement trees required. Replacements required within 30 days.
I hereby certify that as property owner or as representative of the property owner, I have verified that the tree(s) sought
to be removed is wholly on property owned by the above - identified property owner, and should it be determined that
the tree(s) are located wholly or partially on property owned by some other person, then, I agree to hold the City of
Clearwater harmless in any claim made for wrongful removal of such tree(s). I hereby certify that this application together
with any plans submitted is a true representation of all facts concerning the proposed removal of the tree(s). Any deviation
from the ermit ' ued shall render it null and void and be considered a violation of the Community Development Code.
01 c o14."dIR:,!5s #s
Signature of6wrrer or applicant Printed Name
t� /S y C '76 � ► I an „L l o�- N�,�s !� �
Address Agency Representi g OCL #
City State Zip Phone Fax
DO NOT WRITE BELOW THIS LINE - Not Valid Until Signed By City Manor or hi%Designate l Agent I
1�
Applicable Code Section:
Based on the Inspector's comments and information submitted, the above removal application is:
0 Approved as Submitted ;Approved- Modified as Noted Above 0 Denied
Signed: Date: a �
Communi Develop ent Coordinator or Designee /Inspector Valid for d mont s from the date of issuance.
1362.0001 G White - Planning & Development Services Yellow - Applicant Rev. 4 -01
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