Burn Permit (Structure) Information

OWNER:                                                     PHONE #

OWNER'S PRIMARY ADDRESS:

If rented provide tenant's name & phone#:                  

STRUCTURE TO BE BURNT:

STRUCTURE ADDRESS/LOCATION:

BURN PERMIT FEE

$100.00 (TO BE PAID ONCE DNR CLEARANCE IS OBTAINED)

DNR BURN CLEARANCE - DATE RECEIVED:

DATE REQUESTED FOR STRUCTURE TO BE BURNED:

DATE FIRE DEPARTMENT CONTACTED:  

CONTACT NAME:

I THE UNDERSIGNED UNDERSTAND THAT THE COST OF THIS PERMIT IS FOR THE CITY WATER USED DURING THE BURNING OF MY FACILITY AND NOT A CLEARANCE FROM THE CITY, SAC- OSAGE FIRE DISTRICT AND/OR MO DEPARTMENT OF NATURAL RESOURCES.

I THE UNDERSIGNED ALSO AGREE THAT ONCE PROPERTY HAS BEEN BURNT, I HAVE 30 DAYS TO CLEAN UP ALL DEBRIS FROM SITE AND RESTORE PROPERTY TO A CONDITION APPROVED BY THE CITY OF OSCEOLA AND ITS STAFF. IF PROPERTY NOT RESTORED WITHIN 30 DAYS, THE OWNER OF SAID PROPERTY WILL BE ASSESSED A PENALTY OF $100 PER MONTH UNTIL PROPERTY IS RESTORED. I, THE UNDERSIGNED, ACCEPT FULL RESPONSIBILITY AND LIABILITY FOR SAID BURN.

OWNER(S) Signature & Date:  

STRUCTURE BURN PERMIT

JUNE 12, 2012