21 PARK PLACE BLVD NAPPLICATION FOR LAND CLEARING & GRUBBING PERMIT
CITY OF CLEARWATER
PUBLIC WORKS DEPARTMENT
ENVIRONMENTAL MANAGEMENT
(813) 462-6747
DATE
RECEIPT NO.
A non-refundable filing fee of $10.00 is required per Resolution 86-9. Permit applicable for 6 months from date of approval.
In accordance with Section 98.30, I hereby apply for permit to land clear and/or grub the property described below.
1. Location of Property ` �
2. Project Name �
3. Purpose of clearing and/or grubbing , �
4. General description of existing vegetation, topography, and surface water (including all existing and/or proposed
ditches, canals, and swales) -
5. Proposed method of debris disposal
6. Date you plan to begin work � - ,' �' ,.
,
7. Proposed method of soil erosion control % �':
8._,:.�I No-Tree Verification Required (� Tree Removal Permit Required
I AM AWARE AND UNDERSTAND THE REQUIREMENTS OF SECTION 98, CITY CODE OF ORDINANCES REGARDING
TREE PROTECTION DURING CONSTRUCTION AND HAVE READ CITY'S EROSION AND SIL.TATION CONTROL POLICY
Signature of Owner or Owne[,s Representative
Printed Name
Subscribed and Sworn before me
l�:t i .
this day of � g
Address
Signature of Notary
r
NAME OF NOTARY � 4 �---�A `��-1�
City State Zip COUNTY '' � -''� < <; `>
, a' NOTARY PUBLIC STATE OF FLORIDA.
COMMISSION EXPIRESnnv connrnissiarv ExP � nE 17 1995
Representatives' Firm � fs t,w � Telephone BONDED THRU GENERAL INS. UND.
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Applicant must include Aerial Photograph or Scaled Drawing showing property boundaries and limits of work. This is NOT
a Tree Removal Permit.
DO NOT WRITE BELOW THIS LINE
Comments , r, %
Comments
u
l ,:� ..
Water Resource Spec. Date
Urban Forester Date
Based on the above comments and information submitted, the above removal application is:
❑ Approved As Submitted ❑ Approved — Modified As Noted Above L7 Denied
Signed:
City Manager or Designee
White — Applicant
L—
Date:
Yellow — Environmental
Pink — InsFector
Rev. 9/87