Tree Permit Application
Application Date: _____________________________________ Permit No.: ___________________________________________________
PROPERTY INFORMATION
Tree Address: __________________________________________ Parcel Number: _______________________________________________
Applicant Name: ________________________________________ Phone Number: _______________________________________________
Email: _______________________________________________________________________________________________________________________
Additional Reviews/Applications: SEPA Review Critical Area Review Right of Way Use Permit
Draw Site Plan to the Left:
Please show all trees
Number each tree being removed/pruned
Show buildings, roads, property lines, etc.
Example Site Plan:
LIST THE TREES (PRIVATE AND/OR PUBLIC) PROPOSED TO BE REMOVED AND/OR PRUNED:
# from site plan Type/Species Size (diameter) Location Reason for removal/pruning
1-4
Evergreen
Landscape buffer
Dropping limbs on my fence
ADDITIONAL INFORMATION:
Measure or estimate the diameter of the tree trunk at 4½ feet above the ground. Note if there is more than one trunk per tree.
Please contact city staff if the tree is located in a critical area. Additional permitting may be required.
Applicant is required to comply with all City codes and ordinances in effect as of the date of the issuance of the permit.
STATEMENT OF OWNERSHIP AND HOLD HARMLESS AGREEMENT
Statement of Ownership:
The undersigned property owner(s), under penalty of perjury, each state that they are all the legal owners of the
property described herein and authorize individuals or entities identified herein as applicants to file this application
allowing for said property's development.
Authority to Enter Property:
The undersigned property owner(s) do hereby authorize employees of the City of Des Moines to enter onto property
described in this application to examine and inspect as necessary to process this development application.
Hold Harmless Agreement:
The undersigned, certifies under penalty of perjury, the truth and/or accuracy of all statements, designs, plans and/or
specifications submitted with said application and hereby agrees to defend, pay and save harmless the City of Des
Moines, its officers,
employees, and agents from any and all claims, including costs, expenses and attorney's fees
incurred in investigation and defense of said claims whether real or imaginary which may be hereafter made by any
person including the undersigned, his successors,
assigns, employees and agents, and arising out of reliance by the City
of Des Moines, its officers, employees and agents upon any maps, designs, drawings, plans or specifications, or any
factual statements, including the reasonable inferences to be drawn
therefrom contained in said application or
submitted along with said application.
Signature
Signature
Name
Name
STATE OF WASHINGTON
)
)
County of ________________ )
I, the undersigned, a notary public in and for the State of Washington, hereby certify that
on this
___ day of _______, 20____, _________________________ personally appeared before me,
to me known as the individual(s) empowered to execute the foregoing instrument, and
acknowledged that they signed and sealed the same as their free and voluntary act and
deed for the uses and purposes therein mentioned.
NOTARY PUBLIC in and for the State of Washington, residing at ________________ County.
My Commission expires: ___________________________
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