Date _____________________     Permit Application #__________________________________
I hereby certify that this application is correct. It is understood that any deviation from the permit conditions will render the permit null and void and shall be considered as a violation of Pinellas County land Development Code 166.81. This application is for the purpose of developing the below-described property and/or for the purpose of removing: tree(s) for the following reason :
Street Address City Zip
Subdivision Name_______________________________________________________________________

For Officer Use Only
Conditions: Within ______ days, an inspection will be made to verify ______ trees remain, and ______ trees have been planted, 6' in height, 1.5" caliper, selection to be made from the tree replacement species list, being Nursery Grade #1. Undersize trees remaining on site will count toward this requirement if they are of a species on the replacement list, and at least 6' in height and in good condition.

THIS IS YOUR PERMIT AND RECEIPT
Pd. $_____________  Coll. $______________   

CPR # ______________

_________________________________
(Env. Officer's signature)          (date issued)
Directions to site:______________________

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