1 BELCHER RDr " . CITY OF CLEARWATER - ENVIRONMENTAL DIVISION
TREE REMOVAL APPLICATION FORM
NAME OF OWNER: /' quk - I_ �hU�� Fee Rec. $
J' r � Date Rec:
LOCATION OF WORK: OVL Ot<r Nf I V W� Rec. By:
Clearwater, FL Rec't # _
REQUIRED REPLACEMENT TREES �—
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L PERMIT TO REMOVE TREE(S) 126 3
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NAME OF OWNER D lo IOv c, � r REASON FOR REMOVAL:
OWNER'S ADDRESS G y� '" O Construction
PHONE - O Hazardous
SITE ADDRE Kt lvdv 6t v Cl ' W� G. a ❑ Declining
LOCATION OF TREE(S) ON LOT 2 r O Dead
SPECIES AND NUMBER OF TREES) O Other (Specify)
TO APPLICANT: A non - refundable fee of $ 15.00 for up to five trees (� Fee Recd. S
be removed, plus $3.00 for every tree above 5 to be Receipt O
removed is required. Date
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 r I. All easements and Rights -of -Way
b. Structure Locations J. All Protected Trees Including:
C, Driveways and Walks (I.) Diameter of 4.5' above grade (DBi•1)
d. Parking Arrangement .mot., (i1.) Surveyed Location /)
e. Required Number of Parking Spaces (ill.) Species %v
f. Proposed Number of Parking Spaces , (NJ Diseased or Insect Infested Trees t
g. Proposed Underground Utilitles,; (v.) Trees to be Removed
h. Zoning Setbacks ', x x : -;, . k. Tree Barricade Detail & Locations
�s.
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 Specificatlons.
3. Tree replacement minimum standards: 8' overall height, 2' caliper, Florida Grade #1. See Inspectors note below to
determine the number of replacement trees required. Y
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 to-
gether with any plans submitted is d hue representation of all facts concerning the proposed removal of the tree(s). Any
deviation from th permit Issued shall render it null and void and'be considered a vlolation of Chapter 52,, Code of
Ordinances.,
r
Signatur f 15 r or a X&t�, Print d N e �
A 60
Addre . y' �s ='f `,, . ` > �� Agency R presenting (if Not Owner)
P6AM
city Zip ; ' . • Phone
DO NOT WRITE BELO INE I Not Valid Until Signed By City Manager or his Designated Agent
Inspect s omments:
J
Recommended Replacement Trees:
squired Replacement Tre
Code Section: /
z If
Signed: Date
Inspector
Based on the Inspector's comments and Information submitted, the above removal application is:
C] Approved as Submitted proved- Modlfied as Noted Above 0 Denied
Signed: ` �i Date:
City Manager or Design
1362.0001-GC 8-94
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OAK TREE
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