715 FT HARRISON AVE SNAME OF OM
SITE ADDRESS
PHONE Zu
OWNER'S AD[
LOCATION Of
SPECIES AND
HUNT
r
CITY OF CLEARWATER - PLANNING & DEVELOPMENT SERVI I
TREE REMOVAL PERMIT
JUN 10 8 21015i
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.
IkConstrbe
sSee "A" below
CI Hazardous
• Declining
• Dead
• Other (Specify)
Fee Recd. $ 1 1 -
16701M
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: l0' 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.
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 thatthis 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 permit issued shall render it null and void and be considered a violation of the Community Development Code.
Signature of owner or applicant Printed Name
Address Agency Represent ng OCL #
Od aA Ica 'r—L 32 ,910 140 -0445 L107- (029 - %Zq
City State Zip Phone /Cell Fax
DO NOT WRITE BELOW THIS LINE - Not Valid Until Signed By City Manpger or his Designated Agent
Required Replacement Trees:
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 ❑ Denied
Signed � .�..;.. =�_,_. i� ✓:�..1�...r� -.. Date:
Community D velopm nt Coordinator or Designee /Inspector Valid for six months from the date of issuance.
•�... �.��+ �� IAa 1+,.. oi-1 n, rN^. ^1... n +Ccan,iro¢ V=11 —,_ AnMinnnt Rev. 2 -03
VICES DEPT
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s�a��� APPLICATION FOR LAND CLEARING & GRUBB
CITY OF CLEARWATER
TEA. PLANNING DEPARTMENT
(727) 562 -4741
A non - refundable filing fee of $10.00 is required. Permit applicable for 6 months from
In accordance with the Community Development Code, I hereby apply for permit to land clear and /or grub the
property described below.
1. Location of Prog
2, Project Name:
3. Purpose of clearing and /or grubbing: )(New Construction ❑ Demolition 0 Tank Removal 0 Other
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 - r->
r-> 7. Proposed method of soil erosion control
8. a No -Tree Verification Required ATree Removal Permit Required
I AM AWARE AND UNDERSTAND THE REQUIREMENTS OF ARTICLE 3, DIVISION 12 REGARDING TREE PROTECTION
DURING CONSTRUCTION AND ARTICLE 3, DIVISION 7 OF THE COMMUNITY DEVELOPMENT CODE REGARDING
EROSION AND SILTATION CONTROL.
MA-&i: eiz-& L��_ R
l-. Rftwl
Si ature.8Qwn r ners mes Addre / e�
Printed Name 0 1 state Zip
Representatives' Firm er
-4 6-7 -UL1!5-n&1i � �D°7 ®ZA -9124)
Telephone
Applicant must include Aerial Photograph or Scaled Site Plan showing property bound rd iWand limits of work. This is
NOT a Tree Removal Permit.
Land Resource Comments:
DO N()T WRITE RFI r)IAI THIS I IfVF
NOR
Based on the above comments and information, ubmitted, the above clearing & grubbing application is:
0 Approved As Submitted Approved - Modified As Noted Above 0 Denied
R !'
Signed Date: ; JO
City Manager o Designee
CLEARWATER
Brian J. Aungst, Mayor - Commissioner
Hoyt Hamilton, Commissioner Whitney Gray, Commissioner Frank Hibbard, Commissioner Bill Jonson, Commissioner
1362- 0002 -GC White - Planning Department Yellow- Applicant ^ �^
PREPARED BY: KENNEDY TREE - SERVICE, INC. PROPERTY: DOWNTOWN CLEARWATER, FT. HARRISON /PINE ST.
MATTHEW KENNEDY., I.S.A. CERTIFIED ARBORIST
INTERPLAN LLC
TREEINVENTORY
SEPTEMBER 21. 2004
TREE SPECIES TREE TAG # DBH (inches) CANOPY (ft.) RATING 1 = WORST 5. BEST)
E. Polatka Holly 1 lilt 15 2
Live oak 2 21 39 3
Laurel oak 3 8 23' shared 3
Laurel oak 7 canopy
8
Laurel oak 4 10 27 -2.
Laurel oak
5
14
17
2
Laurel oak
6
28
17
2
Laurel oak
7
7
16
1
Lourel oak 8 15 36. 2
Laurel oak
9
6
17
i.
Laurel oak
10
7
22
2
Laureloak
11
4
10
1
Live oak
12
27
5�
3
:INTERPLAN LLC
TREE INVENTORY
SEPTEMBER 21, 2004
TREE SPECIES TREE TAG # D8H (inches) CANOPY (ft) RATING (1 = WORST,' 5 BEST)
Laurel oak .13 21 41 2 1
Laurel oak . 14 16- 21 1
Sabal palm - =- 25 overall good health
Sabal palm 18
Sabal palm 20
Washintonia palm 13
Chinaberry 15 19 38 i
Live oak 16 40 70 4
Sabal palm 13 overall good health
Laurelook
17
9
13
1
Laurel oak
18
14
38
1
Laurel oak
19
33
51
2
Live oak
20
11
17
1
Mango 21 29 34 1
Queen palm 10
INTERPLAN LLC
TREE INVENTORY
SEPTEMBER 21, 2004
TREE SPECIES
-TREE TAG #
O (inches)
CANOPY (ft.)
RATING (1 _WORST 5 = BEST)
Laurel oak
22
14
34
1
Avocado.
23
16
25
2
Laurel oak
24
12
34
3
1
Laurel oak
.25
7
27
3
1
Laurel oak
26
13
32
3
20
1
Cherry Laurel
27
14
27
1
Laurel oak
28
7
18
2
Laurel oak
29
5
12
1
Laurel oak
30
4
10
1
Laurel oak
31
13
20
1
Laurel oak
32
8
21
1
Laurel oak
33
9
27
2
Laurel oak 34 12 36 2
Laurel*oak 35 13 26 :2
Sabal palm 14
a
E
1
:e CL 7
Ll
Li
— --
LAUREL OAK
8
15
36 2
LAUREL OAK
z5
LAUREL OAK
9
6
17 1
LAUREL OAK
26
13
32
3
LAUREL OAK
10
7
22 2
CHERRY LAUREL
27
14
27
1 PROJECT NO: 2003.0608
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A CLEAR UNOBSTRUCTED VIEW SHALL BE MAINTAINED
THROUGHOUT THE SITE VISIBILITY TRIANGLE TO A HED
BETWEEN 30^ AND b" ALL PLANT MATERIAL EXCEPT FD
TRUNKS SHALL BE MAINTAINED FREE FROM VISIBILITY
BEFORE MENTIONED HEIGHT. (TYP)
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PINE STREET
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ARCHITECTURE
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03-02-06 DRC COMMENTS
8
04-05-06 DRC COMMENTS
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09-15-06 CITY COMMENTS
18
10-27-06 POND OUTFALL
nEu�w IN pu�sAuom or 6 mowes
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ORIGINAL ROOT BALL
33.176 PLANTED WITH SHURB8 AND GROUNDCOVER3
(WINGED ELM)
2^ CAL
//8\ \ SOD S[ AUGUST3NE 'F-DR/-AM '
QUANTITY TO BE CALCULATED
51% PROVIDED.
BY THE CONTRACTOR �
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10-08-04 CITY COMMENTS
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03-02-06 DRC COMMENTS
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04-05-06 DRC COMMENTS
14
09-15-06 CITY COMMENTS
18
10-27-06 POND OUTFALL
0 �
MODIFIED: 01/04/07 14:17:47 J:\A-J\AMSOUTH\2003,0608\0360SL1.DWG 1`30' AARFRA
PLOTTED: 01/17/07 13:03:17 J:\A-J\AMSOUTH\2003.0608\0360BL1,DWG 1'=30' AARFRA
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ae«ns AS SHOWN. SUPPORTS SHALL
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�SOUTHBRN �A�NOD�\
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33.176 PLANTED WITH SHURB8 AND GROUNDCOVER3
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2^ CAL
//8\ \ SOD S[ AUGUST3NE 'F-DR/-AM '
QUANTITY TO BE CALCULATED
51% PROVIDED.
BY THE CONTRACTOR �
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««oTo«- THE nom BALL SHALL BE
3F AREk- INTERIOR PARKING TREE:
TD 7AXODlUM DIST3CHUW
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PLANTED TO THE ORIGINAL DEPTH AS IT
,____�
(BALD CYPRESS)
2^ CAL
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QUANTITY T0 BE CALCULATED
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MODIFIED: 01/04/07 14:17:47 J:\A-J\AMSOUTH\2003,0608\0360SL1.DWG 1`30' AARFRA
PLOTTED: 01/17/07 13:03:17 J:\A-J\AMSOUTH\2003.0608\0360BL1,DWG 1'=30' AARFRA
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570-8-F
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1/3 O^ POP-UP SPRAY HEAD
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DATE: 05-24-04
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15' -
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MODIFIED: 01/04/07 14:22:0 1*=30' wmpRA
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ARCHITECTURE
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TREE "RE E M N r-J'
� cl a
^~�^~''~ }( LAUREL OAK 14 1G 2� 1 X LAUREL OAK 51 13 20 1 | �
>( LAUREL OAK B 21 \
>( SABAL P&L --- 25 OVERALL GOOD HEALTH J2
)( SA8AL PALM 18 ~ >( LAUREL OAK 33 9 27 2
SABAL PALM 20 ^ >( LAUREL OAK 34 12 35 2
I/ImN . |
WASHlN[TONlA PALM 13 X LAUREL OAK 35 13 26 2 |
'»'u"'^/ )( CHINABERRY 15 19 JD 1 SA8AL PALM 14 �
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LIVE OAK 16 40 70 4 X LAUREL OAK 24
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MODIFIED: 01/04/07 14:23:5 J:
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PROJECT NO: 2003.0608
DATE: 05-24-04
A3
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CHECKED: RTA
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1'=30' AARFRA
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EXISTING TREE TO R
REMAIN /
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MINIMAL GRADE C
CHANGES ARE ALLOWED TO OCCUR,
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PER CITY OF CLEARWATER R
E
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EXISTING TREE TO B
BE REMOVED A
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TREE SPECIES T
TREE D
DBH (INCHES) C
CA�aY-4�/ |
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TREE SPECIES T
TREE 883 R
R8f_(LNK%HE�> C
CANOPY
/
/
)( 5
5ABAL PALM 1
13 O
OVERALL GOOD HEALTH |
)( E
E. PALAJKA HOLLY 1
1 1
11 1
15 2
2 >
>( L
LAUREL OAK 1
17 Q
Q 1
13 1
1
X L
LIVE OAK 2
2 2
21 3
39 3
3 )
)( L
LAUREL &4K l
lH 1
14 3
38 1
1 i
• L
LAUREL OAK 3
3 8
8 2
23' SHARED 3
3
)( L
LAUREL OAK 1
19 3
33 5
51 2
2 |
• L
LAUREL OAK 3
3 7
7 C
CANOPY X
X L
LIVE OAK 2
20 1
11 1
17 1
|
J B
B )
)( M
MANGO 2
21 2
29 3
34 1
|
X L
LAUREL OAK 4
4 1
10 2
27 2
2 Q
QUEEN PALM ^
^ 1
10 �
�
)( L
LAUREL OAK 5
5 1
14 1
17 2
2 >
>( L
LAUREL OAK 2
22 1
14 3
34 1
1 �
)( L
LAUREL OAK G
G 2
28 1
17 2
2 )
)( A
AVOCADO 2
23 1
16 2
25 2
2 �
)( L
LAUREL OAK 7
7 7
7 1
16 1
1 )
)/ L
LAUREL OAK 2
24 1
12 3
34 3
3
X L
LAUREL OAK 8
8 1
15 3
36 2
2 X
X L
LAUREL OAK 2
25 7
7 2
27 3
i
X L
LAUREL OAK Q
Q 0
0 1
17 1
1 )
)( L
LAUREL OAK 2
26 1
13 3
32 3
3
>( L
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10 7
7 2
22 2
2 X
X C
CHERRY LAUREL 2
27 1
14 2
27 1
1 !
)( L
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11 4
4 1
10 1
1 )
){ L
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28 7
7 1
18 2
2 �
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12 2
27 5
53 J
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29 5
5 1
12 1
1
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1J 2
21 4
41 2
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4 1
10 1
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MODIFIED: 01/04/07 14:23:5 J:
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PROJECT NO: 2003.0608
DATE: 05-24-04
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OFFICES
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(TYP) I L13 DRUID ROAD 20 32
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TIE–IN SURVEY (CITY D&NSD POLICY MEMO #022)
WILL BE REQUIRED TO BE SUBMITTED PRIOR TO
COMMENCING ONLY FURTHER WORK AFTER THE
FOUNDATION IS COMPLETE. THIS SURVEY WILL M
INDICATE THE BUILDINGS LOCATION ON THE LOT,
__ .41-1011
m
CITY NOTE:
A CITY RIGHT OF WAY PERMIT SHALL BE OBTAINED AT LEAST 48 HOURS PRIOR
TO COMMENCEMENT OF ANY CONSTRUCTION IN CITY STREET RIGHT'S OF WAY,
r5V! TRAFFIC CONTROL &
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1, CLEAR SDE OF ALL 0J1U8N6S STRUCTURES, PAVEMENT AND unv»�C*'/mo SAW CUT AND REMOVE EXISTING CONCRETE WALK.
PLAT D LOT.
' [ PLR SPECIFICATIONS UNLESS U|MLKWiSE SPECIFIED ON THE ruo/ ruyv OR
En
' /
Q, CO r CONFIRM WITH A BY THE OWNER'S -F�l
SOI VISD. ! � | OPEN CUT EXISTING PAVEMENT, |
/ F C3 2 ^ CONTRACTOR SHALL BE RESPONSIBLE FOR NOTIFYING UTILITY COMPANIES TO
[��l
LOCATE ALL UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION. | � | REMOVE EXISTING CURB AND DRIVEWAY.|
{ t5 -------- - 3. RESTORE T0 ORIGINAL OR BETTER CONDITION ALL AREAS DISTURBED BY
-' ( CONSTRUCTION
F-�l RELOCATE TRAFFIC SIGNAL UTILITY BOX (T.S.B.). COORDINATE �
� ^ �J ``_/ WITH APPROPRIATE AUTHORITIES �
4 ` EXISTING UNDERGROUND UTlLIT\E5, UNLESS OTHERWISE NOTED` SHALL
L/ '~
Kl `' " ~ REMAIN AND ARE T0 BE PROTECTED WHERE NECESSARY.
EXl3JlNC TREES TO BE REMOVED. �YP.\ |
- L] 5. REMOVE ALL PRODUCT PlPlNG, VENT LINES AND RISERS, ISLANDS AND ^ ' �
OD
/ a� UTlLlTIES BOXE8 PER �TATE OR LO�AL ORDlNANCES' F�� EXISTING TREES TO REMAIN, �YP.\ �
5. CONTRACTOR SHALL REMOVE AND DISPOSE OF THE CONCRETE AND SOIL AS �
NECESSARY T0 COMPLETE PROPOSED CONSTRUCTION. ANY IMPACTED SOILS F��} CONTRACTOR SHALL VERIFY LOCATION OF EXISTING WATER
\/|
°
ENCOUNTERED SHALL BE STOCK PILED PER DIRECTION OF OWNER' S METERS, BACKFL0V PREVENTERS AND VALVES. COORDINATE
/ x»o^`r� _ REPRESENTATIVE UNLESS OTHERWISE DIRECTED, CONTRACTOR SHALL USE ALL \ REMOVAL OF ANY EXTRA METER(S) AND CAPPING OF SERVICE
i !A �
''p.`___i��'_- _ ---'_- ��----- -----------'-----� ----�----- ---------- -'---_m EXCAVATED SOILS.
LINE(S) WITH THE UTILITY PROVIDER. |
----
7. REMOVE AND DISPOSE OF SEPTIC TANKS, GREASE TRAPS AND LEACH FIELDS |
IN THEIR ENTIRETY, PER STATE AND LOCAL HEALTH CODES INCLUDING [��\ CONTRACTORS SHALL REMOVE ALL CURBS CONCRETE PAVEWENT �
' 3E�ER PIPE SEPTIC TANKS FIELD LINES AND ALL BELOW GRADE
| v | ' '
' ^--^ ASPHALT AND BASE COURSE DESIGNATED WITHIN PROJECT
APPURTENANCES. FILL EXCAVATIONS YYD0 APPROPRIATE MATERIAL LIMITS. ' DISPOSAL, INCLUDING ANY HAZARDOUS MATERIALS
bnc
!
ACCORDING TO LOCAL CODE3 �
� ENCOUNTERED, SHALL BE IN ACCORDANCE WITH APPLICABLE �
LOCAL, TATE AND FEDERAL RULES AND REGULATIONS.
(60 ^ R� ^ 8. CONTRACTOR SHALL BE RESPONSIBLE FOR LAYOUT OF THE ENTIRE SITE. THE ' '
} � 0 pROpERTY C0RNERS SHALL BE MARKED. IF CORNER PINS ARE REMOVED DR
DISTURBED DURING CONSTRUCTION, CONTRACTOR SHALL REMARK PROPERTY REMOVE EXISTING DRIVEWAY, FLUME, CONCRETE APRON ! /
CORNERS AT HIS EXPENSE USING A REGISTERED SURVEYOR. - L�J AND CURB. ^ � |
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403400-01
9, THE SITE DEMOLITION DEBRIS INCLUDING SUCH ITEMS AS FENCES, WALLS
FOUNDATIONS, LOGS, SHRUBS, BRUSH, WEEDS, OTHER VEGETATION AND
R RECRADE EXISTING RETENTION POND. (SEE SHEET C3).
933 LEE ROAD, FIRST FLOOR
ORLANDO, FLORIDA 32810
PH 407,645.5008
FX 407,6299124
DATE: 05-24-04
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REVISIONS:
FT
NO, DATE REMARKS
IINIEHIUH IJENQ�N
35.0—
3 05-04-05 CITY, SWFWMD & FDOT
4 09-30-05 DRC COMMENTS
5 11-09-05 DRC COMMENTS
A
7 03-02-06 DRC COMMENTS
PROJECT MANAGEMENT
8 04-05-06 DRC COMMENTS
AA 004320
15 09-26-06 IP QC
17 10 -18-06 CITY COMMENTS
------- ---- — .... ...
7
20 11-20-06 CITY COMMENTS
22 11-30-06 OWNER REVISIONS
CA 8660
25 01-03-07 CITY REVISIONS
S, 89054'05'W (0 2
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1 ST FLR —
7,500 SIF
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2ND FLR —
7,5 SF�—
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40.00
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ORLANDOFLORIDA 32810
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PINE STREET
N 89*48'3'E (F) - -3---8
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REVISIONS:
FT
NO, DATE REMARKS
IINIEHIUH IJENQ�N
35.0—
3 05-04-05 CITY, SWFWMD & FDOT
4 09-30-05 DRC COMMENTS
5 11-09-05 DRC COMMENTS
A
7 03-02-06 DRC COMMENTS
PROJECT MANAGEMENT
8 04-05-06 DRC COMMENTS
AA 004320
15 09-26-06 IP QC
17 10 -18-06 CITY COMMENTS
------- ---- — .... ...
7
20 11-20-06 CITY COMMENTS
22 11-30-06 OWNER REVISIONS
CA 8660
25 01-03-07 CITY REVISIONS
S, 89054'05'W (0 2
A
IN
J
933 LEE ROA, FIRST FLOOR
ne. r—
ORLANDOFLORIDA 32810
PH 407645,5008
2 4
-------------
- ----- - -- -JI
PINE STREET
N 89*48'3'E (F) - -3---8
36 O/A — -
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FT
NO, DATE REMARKS
35.0—
3 05-04-05 CITY, SWFWMD & FDOT
4 09-30-05 DRC COMMENTS
5 11-09-05 DRC COMMENTS
A
7 03-02-06 DRC COMMENTS
8 04-05-06 DRC COMMENTS
9 07-07-06 RFI REVISIONS
15 09-26-06 IP QC
17 10 -18-06 CITY COMMENTS
------- ---- — .... ...
7
20 11-20-06 CITY COMMENTS
22 11-30-06 OWNER REVISIONS
23 12-13-06 CITY REVISIONS
25 01-03-07 CITY REVISIONS
S, 89054'05'W (0 2
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FT
NO, DATE REMARKS
35.0—
3 05-04-05 CITY, SWFWMD & FDOT
4 09-30-05 DRC COMMENTS
5 11-09-05 DRC COMMENTS
A
7 03-02-06 DRC COMMENTS
8 04-05-06 DRC COMMENTS
9 07-07-06 RFI REVISIONS
15 09-26-06 IP QC
17 10 -18-06 CITY COMMENTS
------- ---- — .... ...
7
20 11-20-06 CITY COMMENTS
22 11-30-06 OWNER REVISIONS
23 12-13-06 CITY REVISIONS
25 01-03-07 CITY REVISIONS
S, 89054'05'W (0 2
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15 16 C�o� 3 6
8 BUILDING, SEE ARCHITECTURAL PLANS FOR EXACT LOCATION,
13 7
FOR FIRE, DOMESTIC, AND IRRIGATION
Ij INV� 36.37
(1) SERVICE LINES,
(Typ)
5 12 DRUID ROAD 5, C5 PROPERTY ID # FLWC03078RL
8 LF — 8" D.I.P^
8
1-7 /" 6Z -rvn� F1FrTRTr 71 A R FT 14APPI-qON AVP
I- 41��D
6 (60' R/W)
/15
2
CONTRACTOR SHALL DEFLECT PROPOSED WATER LINE TO
INSTALL A MINIMUM OF 2' BELOW PROPOSED WALL
FOOTER.
1 " =3G
REVISIONS:
FT
NO, DATE REMARKS
2 08-11-04 DRC COMMENTS
3 05-04-05 CITY, SWFWMD & FDOT
4 09-30-05 DRC COMMENTS
5 11-09-05 DRC COMMENTS
A
7 03-02-06 DRC COMMENTS
8 04-05-06 DRC COMMENTS
9 07-07-06 RFI REVISIONS
15 09-26-06 IP QC
17 10 -18-06 CITY COMMENTS
20 11-20-06 CITY COMMENTS
22 11-30-06 OWNER REVISIONS
23 12-13-06 CITY REVISIONS
25 01-03-07 CITY REVISIONS
14
15 16 C�o� 3 6
8 BUILDING, SEE ARCHITECTURAL PLANS FOR EXACT LOCATION,
13 7
FOR FIRE, DOMESTIC, AND IRRIGATION
Ij INV� 36.37
(1) SERVICE LINES,
(Typ)
5 12 DRUID ROAD 5, C5 PROPERTY ID # FLWC03078RL
8 LF — 8" D.I.P^
8
1-7 /" 6Z -rvn� F1FrTRTr 71 A R FT 14APPI-qON AVP
I- 41��D
6 (60' R/W)
/15
2
CONTRACTOR SHALL DEFLECT PROPOSED WATER LINE TO
INSTALL A MINIMUM OF 2' BELOW PROPOSED WALL
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NO. DATE fE11ifKS
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EMPORARY CONSTRUCTION
BARRIER ROAD
— ----� f� -� ----7� — ----- �� --
P.S.I. (28 DAYS) COARSE AGGREGAW1
Bonnnukp RdluUuu Prevention Plan Inspection Report Form
nspections must occur at least once o week and within 24 hours of the end of o storm event
hot is 0.50 inches or Oeoter,
Iroject
onclition Code,
= Good M = Marginal, needs maintenance or replacement soon
= Poor, needs immediate maintenance or replacement C = Needs to be cleaned
= Other
.mntnn} Tvoe Codes
'28. Tree protection
�31_ftte diSDosal/housekeep
Detention pond
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�30. Retention pond
Inspector Information:
Nome Date
0ooNicohon
The above signature also ohoU certify that this (od||ty is in compliance with the Stormnohar
Pollution Prevention Plan and the 8oto of Florida Connho Permit for 5honnwohor Discharge from
Large and Small Construction Activities if there ore not any incidents of nun-oump|ionoo
identified above,
^***^*
l certify under penalty of |m, that this document and all attachments were prepared under
direction or supervision in noourdonmo with a system designed to ommm that qualified personnel
properly gathered and evaluated the information submitted, Based on my inquiry of the parson
or persons who manage the sydem, or those pomunn directly responsible for gathering the
7nfn/moOon, the information submitted is, to the best of my knowledge and bo|ief, true,
ocoumte, and complete. l am ovora that there are significant psno|Uns for submitting kz|aa
infonnniion, including the possibility of fine and imprisonment for knowing ,kdoUons,^
----------- _---------- _----- ______________
Nome (Responsible Authority) Dote
|
NOTE: THIS EXAMPLE INSPECTION LOG IS GIVEN FOR REFERENCE PURPOSES. THIS OR A SIMILAR
CONTRACTOR(S) AND SUBCONTRACTOR(S) THAT IMPLEMENT ANY PART OF THE
EROSION/POLLUTION CONTROL MEASURES REQUIRED BY THE NPDES PERMIT SHALL SIGN BELOW:
| °-_- |r3'- m.... ^AA~.. P, .k... ....k.- |n.^~ | C
1 certify under penalty of low that this document and all attachments were prepared
under my direction or supervision in accordance with a system designed to assure that
qualified personnel properly gathered and evaluated the information submitted. Based on
my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment
for knowing violations,"
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PROJECT NO: 2003.0608
DATE: 05-24-04
C31
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