HomeMy WebLinkAboutBRN2009-00054 - BRN Application - 12/16/2009 PERMIT NO.
MASON COUNTY BURN PERMIT APPLICATION
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360)427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269 •www.co.mason.wa.us
APPLICWT INFORMATION CONTRACTOR IV,-ORMA ON •
Owner J Company Name S S1 0 C4 v
Mailing Address Mailing Address
City State Zip Code City I A State Wq Zip Code
Phone Other Ph. Phone Other Ph.
Contractor Reg. #115=L Exp.
ss E Mail Address �—
_QG& Drivers Lic. # DOB
PARCEL INFORMATION - 12 Digit Parcel No — I r7 L4 Fire District
13 Is property flagged or addressed prior to inspection? Yes / No i
Site Address(Please include street ngWLn,, street n mber a ity) t
Directions to site
Will timber be cut and sold in parcel preparation?Yes No
Is property within 200' of Saltwater Lake River/Creek Pond n
Wetland Seasonal Runoff Stream—Slopes or Bluffs > 15%
/A—
The person in charge of the fire may be liable for the cost of fire supression if the fire gets out of control or if it becomes
necessary to extinguish the fire as a result of enforcement action.
Open burning shall be prohibited during any period of impaired air quality as designated by the Olympic Region Clean
Air Agency, or during extreme fire danger due to dry weather conditions as designated by the Mason County Fire
Marshal's Office.Information hotline(360)427-7799
;alFiid
is permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action? Yes t9l
Burning is authorized subject to the following conditions:
permit must be on site while burning
hibited materials.the following must not be burned:
Garbage,dead animals,asphalt, petroleum products, paints, rubber products, plastics, paper,cardboard,treated wood,
/1c0nstruction/demolition debris, metal, or any substance(other than natural vegetation)that normally releases toxic
emissions, dense smoke,or obnoxious odors when burned.
EW materials must originate from the property on which the burning is to occur.
he fire must not create a nuisance from smoke,obscure visibility on public roads and highways,or endanger life and property.
aximum pile size is twenty(20)feet in diameter,a minimum ten(10)feet firebreak must be constructed around each pile.
�ach pile must be at least one hundred(100)feet from any structure, at least fifty(50)feet from standing timber.
o not burn if wind is blowing more than seven(7)miles per hour.
o not burn if wind is blowing from (direction)
responsible adult and equipnLELnt shall be required to be on site and in attendance at the fire while burning.
site water required: Mes No
ovide EXCAVATOR/DOZER with a fire extinguisherat the site with a qualified operator.
ovide 24 hour fire watch.
rron
Fire must be completely extinguished within three(3)days after ignition.
F
- Othed 13 Upon completion of above conditions,applicant must call(360)427-9670 Ext.459 for inspection prior to burning
OWNER/CONTRACTOR Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below. I declare that I am the owner,owners legal representative,or the contractor. I further declare that I
am entitled to receive this permit and to do the work as proposed in the application. I declare that I have obtained the permission from all the neces-
sary parties. If permission is required from any easement holder or any other parry in interest regarding this application or the work proposed in the
application, I have obtained permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,
represents that the information provided is accurate and grants employees of Mason County access to the above described property for review and
inspection.This permit/application becomes null and void if work is not completed within 30 days. Permit includes two(2) inspections maximum,
additio I inspections will reqtAre,a fee of sixty four(64)dollars per inspection. i
X Date:
caner/Owners Representative/Contractor indicate which one
FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Date I
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Fire Marshal
FEES
Burn Permit Fee Site Inspection Violation Fee
State Fee Pre-Paid at Submittal Other
TOTAL FEES