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2. 
3. City of St. Anthony Fire Department
   3505 Silver Lake Rd NE St. Anthony, Minnesota 55418 Phone: 612-782-3403 or 612-782-3400 Fax: 612-781-0594
4. APPLICATION FOR PERMIT
   RECREATIONAL / CAMPFIRE
5. Date:
   Date:
7. Name
8. DOB:
10. Address
12. City
13. State
14. Zip Code
16. Email Address
18. Phone Number
22. BURN SITE INFORMATION
24. Address:
26. City:
27. State:
28. Zip Code:
32. OTHER PROPERTY OCCUPANTS AUTHORIZED
    Must be 18 years of age and older. At least one of the persons named below must be in attendance at all times of the burn.
34. Name:
35. DOB:
37. Name:
38. DOB:
40. Name:
41. DOB:
43. Name:
44. DOB:
48. NAME OF PROPERTY OWNER IF NOT LISTED ABOVE
50. First/last name:
52. Address:
54. City:
55. State:
56. Zip Code:
58. Phone Number:
60. As property owner for the above address, I allow those persons listed on this application to conduct recreational / campfires as stipulated in the permit.
62. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature
65. Date:
    Date:
69. I, the undersigned, a legal adult of eighteen (18) years of age or older and the legal representative of the above listed property; understand this permit does not release me of any liability for damages that may result wherefrom. I understand and have received a copy of the recreational/campfire regulations. I agree to comply with all the requirements. A person violating any provision of this permit is guilty of a misdemeanor.Issuin
71. Print first name:
73. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Electronic Signature
76. Date:
    Date:
80. Issuing authority name:
82. Issuing authority signature:
83. Date:
    Date:
85. Permit number:
86. Expiration date:
87. Cert. issued:
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit

* indicates a required field