1119 FAIRBURN AVEI
CITY OF C#.EA%t�A�� --
NAME OF OWNER _ P-v
SITE ADDRESS
PHONE
OWNER'S ADDRESS Z/2- a
LOCATION OF TREE(S) ON LOT —
SPECIES AND NUMBER OF TREE(S)
fl. C P. ,,O ENT& GGIN t
ATER - PLANNING & DEVELOPMENT SERVICES
TREE REMOVAL PERMIT
rA
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:
Oi Construction
-See "A" below
❑ Hazardous
• Declining
• Dead
• Other (Specify)
Fee Rec'd. $
Date
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
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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 D
1. Tree replacement minimum standards: 10' overall height, 2.5" caliper, Florida Grade #1. See inspectors note below to
determine the number of replacement trees required. Replacements required within 30 days. cn
I hereby certify that as property owner or as representative of the property owner, I have verified that the tree(s) sought y
to be removed is wholly on property owned by the above - identified property owner, and should it be determined that m
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 My claim made for wrongful removal of such tree(s). I hereby certify that this application together
with any plans submi d s a true representation of all facts concerning the proposed removal of the tree(s). Any deviation
from the per issu d all render it null and void and be considered a violation of the Community Development Code.
Of
Signa `re of ow r or applicant Print 9d Name
/7/1 0,0�c f�1" tom. �i �i' ' �/C
Add r Agency Representing OCL #
City State Zip Phone /Cell Fax
DO NOT WRITE BELOW THIS LINE - Not Valid Until Signed By City Manager or his Designated Agent
Required Replacement Trees:
Applicable Code Section:
Based on the Inspector's comments and information submitted, the above removal application is:
❑ Appr d as Submitted ❑ Approved - Modified as Noted Above ❑ Denied
Signed- Date: �!
Community eevelopment Coordinator or Designee /Inspector Valid for six months from the date issuance.
1362.0001 -GC White - Planning & Development Services Yellow - Applicant Rev. 2-03
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