City of Roseburg Fire Department

Burn Permit Request

Note: The burn permit requestor must fill out the fields below with current and accurate information to the best of their knowledge. Incorrect or falsified information may result in a rejection of the permit or an investigative inquiry of the requestor.

Requestors Name: _____________________________________________________

Current Address: _____________________________________________________

Day Time Phone: _____________________________________________________

E-Mail (optional): _____________________________________________________

Location of Burn: _____________________________________________________

Application Date: _____________________________________________________

Requestors Signature: _______________________________________________ Fire Marshal Use Only

Approved By: _____________________________________________________

Approval Date: _____________________________________________________

Special Conditions: _____________________________________________________

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