OFFICE USE ONLY

Date:        /           / 2008

Receipt No:

Permit No:  2008-

 
 

211 Walnut Street, P.O. Box 426, Neenah, WI   54957-0426

Phone:  (920 ) 886-6100   Fax:  (920) 886-6109

 

RECREATIONAL FIRE PERMIT APPLICATION

 

PLEASE PRINT

 

                                                                                                                                                           

Name:                     (First)                              (Middle Initial)                                    (Last)

 

                                                                        Neenah                            WI                     54956      

Street Address:                                             City:                               State:              Zip Code:

 

 _____________                  _________________         

 Home Phone                                    Cell Phone

 

Permit Fee:  $15.00 per year

Expires:  December 31, 2008_ (Permits expire December 31st of the calendar year in which they are purchased)

 

        All of the above information is accurate and complete.

 

        I have received a copy of City Ordinance No. 1247 and agree to comply with all the provisions of that ordinance.  I hold the City of Neenah harmless from any damages caused by my recreational fire.  In addition to any other penalties authorized by law, this permit may be revoked for noncompliance of Ordinance No. 1247.  I understand a copy of this Ordinance and the permit must be made available upon the request of the Police or Fire Department.

 

 

_______________________________________

Applicant's Signature                                                                      

           

 

Subscribed and sworn to before me this ______

day of ____ _______________________  2008.      

                                                                                                                       

                                                                                                           

City Employee Issuing Permit or Notary Public - seal