Fillable CITY OF PERRYVILLE APPLICATION FOR PERMIT TO OPEN (City of Perryville, Missouri)

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CITY OF PERRYVILLE APPLICATION FOR PERMIT TO OPEN (City of Perryville, Missouri)

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CITY OF PERRYVILLE
APPLICATION FOR PERMIT TO OPEN BURN
VEGETATIVE OR UNTREATED WOOD
APPLICANT INFORMATION
SITE INFORMATION
APPLICANT NAME
PERMIT NUMBER
COMPANY NAME
COMPANY ADDRESS
PRIMARY TELEPHONE WITH AREA CODE
CITY
PREFERRED METHOD OF DELIVERY OF
COMPLETED PERMIT
EMAIL ADDRESS
ZIP CODE
ALTERNATIVE TELEPHONE NUMBER WITH AREA CODE
FAX NUMBER WITH AREA CODE
☐EMAIL ☐FAX ☐POSTAL
MAIL
Signed waivers from all home/business owners and/or an Air Curtain Destructor, or ACD, are required when vegetative waste is to be burned within 200 yards
of an occupied structure. An ACD may also be required as a special permit condition.
SITE NAME (SUBDIVISION OR DEVELOPMENT NAME)
NAME OF INDIVIDUAL WHO WILL CONTROL THE BURN
TELEPHONE NUMBER WITH AREA CODE
SITE LOCATION (STREET ADDRESS)
CITY
COUNTY
WILL AN AIR CURRENT DESTRUCTOR
BE USED AT THIS SITE?
DIRECTIONS-ALSO SUBMIT A MAP OR PROVIDE GPS COORDINATES OF THE BURN SITE LOCATION
DISTANCE TO NEAREST OCCUPIED STRUCTURE (YDS)
TYPE OF MATERIAL TO BE BURNED
☐Tree Trunks ☐Tree Limbs ☐Leaves ☐Brush ☐Untreated Wood
ARE ALL RELEVANT WAIVERS ATTACHED?
LAND DISTURBANCE PERMIT NUMBER (IF
APPLICABLE:
EXAMPLE: DISTURBED AREA >1 ACRE)
FIRE DEPARTMENT INFORMATION
LOCAL FIRE JURISDICTION
FAX NUMBER WITH AREA CODE
TELEPHONE NUMBER WITH AREA CODE
MAILING ADDRESS
PHYSICAL ADDRESS
EMAIL
CITY
STATE
ZIP CODE
APPLICANT CERTIFICATION AND CITY OF PERRYVILLE FIRE DEPARTMENT APPROVAL/DENIAL
I certify that:
• The information in this application is true and accurate to the best of my knowledge.
• I have read and will comply with the standard conditions and any special permit that may be required.
• The City may revoke this permit if conditions are violated or a complaint or nuisance is created by the open burning.
• This permit will be effective for 60 days from approval unless otherwise terminated.
• In no way does this permit relieve me of my obligation to comply with all applicable federal, state, and local laws or regulations.
APPLICANTS’ SIGNATURE
PRINT APPLICANT NAME
DATE
CITY OF PERRYVILLE FIRE DEPARTMENT SIGNATURE /TITLE
REASON DENIED OR SPECIAL CONDITIONS OF APPROVAL
ANY ADDITIONAL SPECIAL CONDITIONS
DATE
Perryville Fire Department
573-547-2261
573-547-4545
120 N. Jackson Street
301 W. Ste Marie Street
Perryville
MO
63775
fire@cityofperryville.com
MO-R
☐ YES ☐ NO
☐ YES ☐ NO
Approved
Denied
For Office Use Only
DATE RECEIVED
For Office Use Only
(E-Mail this application to fire@cityofperryville.com
(See Page 2 - Standard Conditions)
1. The permission to burn in no way relieves the permittee of their obligation to comply with any other
local, county, state or federal rules or regulations.
2. This application becomes the burn permit once signed by the designated Fire Department
representative. Before any burning takes place, the permittee must submit to the City of Perryville
Fire Department, a completed application.
3. A representative/employee of permittee shall be present during all burning to ensure compliance
with this permit and to make certain the fire(s) are out after 5:00 p.m.
4. Only tree trunks, tree limbs, leaves and brush originating on the site may be burned. For permits
allowing the burning of untreated wood, only waste meeting the definition of “untreated wood” may
be burned.
5. The distance from the burn site to the nearest occupied structure (residence or business) must be
greater than 200 yards, unless an Air Curtain Destructor is used or waivers were obtained.
6. Burning will take place between 7:00 a.m. and 5:00 p.m. and within any more restrictive burn times
that may be applicable. Any exceptions to the time frame will be specifically stated on the burn
permit.
7. Should a problem arise from the burning, such as a public health hazard, nuisance, or a hazard to
vehicular or air traffic, the permittee must correct the problem immediately.
8. This permit is effective for 60 days from the date issued.
9. This permit will be revoked immediately for failure to fully comply with any of the conditions and
restrictions.
10. The permittee shall notify the Fire Department each day before starting any burning at 573-547-
4545.
11. Any other permits, if required by the State of Missouri Department of Natural Resources (i.e. NPDES
Land Disturbance Permits), must be applied for and obtained. Failure to do so may result in
termination of this permit. Please contact your local Regional Office regarding other possible
permitting requirements.
12. Permittee authorizes the City of Perryville Fire Department personnel to enter the site at any time
during the term of this permit for inspections and permit compliance determinations. If this permit is
terminated or revoked for any reason, a full application must be resubmitted.
Untreated wood – Lumber and other wooden materials that have not been chemically treated for
resistance or moisture, fire, fungi, insects and other pests, or has not otherwise been treated or
manufactured with chemicals, or that does not contain adhesives or resins. Untreated wood does not
include plywood, particleboard, chipboard or wood with other than insignificant quantities of paint,
coating or finish.
All tree and vegetation materials suitable for other uses such as fireplace wood, posts, saw logs, etc.
should be removed prior to burning.
SPECIAL CONDITIONS
DEFINITION
OPEN BURN PERMIT STANDARD CONDITIONS
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CITY OF PERRYVILLE APPLICATION FOR PERMIT TO OPEN (City of Perryville, Missouri)

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Completed 23 July 2021

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