Issued to (Name & Address): ____________________________________________________________________________
For Burning (describe materials) _______________________________________________________________________
At (location) __________________________________________________________________________________________
Beginning _________________________________ 20____ and ending _____________ 20_____

This permit does not relieve the applicant from responsibility should the fire escape.
This permit does not authorize burning without landowner's consent.
This permit shall be Invalid unless dated.
This permit shall be void should a hazard develop adjacent to the fire and not be eliminated during the tenure of this permit.
This permit does not relieve the applicant from responsibility for compliance with Air Pollution Control Commission and West Virginia Department of Health regulations.

ESCAPE OF FIRE TO PROPERTY OF ANOTHER: Any person or his agent or employee who shall set or cause to be set any fire at any time in the use and occupation of any land on which the burning was being done, or who shall permit any such fire to escape to the land of another, shall be in violation of the provisions of this permit.

ARTICLE 1517.02 OPEN BURNING PROHIBITED; GENERAL PROVISIONS.
The open burning of refuse for the purpose of volume reduction, elimination or product recovery by any person, firm, corporation, association or public agency is prohibited except for the following exemptions, subject to the applicable permit requirements in Section 1517.04:

(a) Vegetation grown on the premises of a home or farm, provided consideration is given to the effect of such emission on the air quality of the area affected by such burning, and the health safety, comfort and property of persons are protected from the effects of such burning.
(b) Fires set for the purpose of bona-fide instruction and training of public and industrial employees in the methods of fighting fires, provided that approval to conduct such burning is received from the Director of the West Virginia Air Pollution Control Commission or his duly authorized representative.
(c) Open burning of construction and demolition wastes, provided that all the following conditions are met:

ARTICLE 1517.04 PERMITS.
Whenever any person, firm, corporation, partnership, association or public agency seeks to avail itself of exemptions in Section 1517.02 for the open burning of refuse or open burning of construction and demolition wastes, it shall be unlawful for such open burning to occur without first a permit being obtained from the Fire Chief or his authorized representative. The Fire Chief or his authorized representative, in granting a permit, shall have the right to prescribe conditions for such open burning in order to protect the health, safety, comfort, and property of the public, as well as to ensure that such open burning conforms to existing and applicable law. The Fire Chief or his authorized representatives are empowered to make inspections upon premises in a reasonable manner prior to the issuance of any permit under this section.

NO PERMIT WILL BE ISSUED FOR LONGER THAN 10 DAYS

I have read the entire permit and agree to follow and comply with all the laws and regulations set out in this permit.

I declare under penalty of perjury under the laws of the State of West Virginia that the foregoing information supplied by the undersigned is true and correct.