No. 08- ____

CITY OF MENASHA

RECREATIONAL FIRE APPLICATION/PERMIT

PLEASE TYPE OR PRINT

Date of Application __________/__________/__________

Applicant ________________________________________________

Street Address ____________________________________________

Telephone Number ________________________________________

_______ I am the property owner

_______ I am a tenant (if tenant, must provide approval from property owner)

___________________________________ (property owner’s signature)

All of the above information is accurate and complete. I hold the City of Menasha harmless from any damages caused by my recreational fire. I have received a copy of City Code 5-2-7. I understand and I agree to comply with all provisions of City Code 5-2-7. In addition to any other penalties authorized by law, this permit may be revoked for noncompliance of City Code 5-2-7.

Applicant Signature _________________________________________

For City of Menasha Office Use

Annual fee of fifteen dollars ($15) collected on ________/________/________

________________________________________

Clerk/Deputy Clerk signature

For Recreational Fire Permit expiring on December 31, 2008.