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<br />RECElVED <br />MAY 30 Z006 <br /> <br />(FOR USE BY LOCAL JURlSDICfIONS) <br /> <br />SAMPLE APPLICATION I PERMIT <br />DISPLAY OF FlREWORKS/PYROTECHNIC SPECIAL EFFECfS <br /> <br />CENTERVILLE, MN <br /> <br />App6cant instruetioDs: <br />1. This application must be completed and returned at least 15 days prior 10 date of display. <br />2. Fee upon application is S ~ and must be made payable to ~ <br />Name of applicant (Sponsoring Organization): J:-Je- des~.s ~dl'\r.A <br />Addressofapplicant Hf:r - hr~ fJ-.r,. /S'7 A-t1f--fJr ~-... I'1.IV' <br />Name of authorized agent of applicant: 1'1 (Y" ~~ -- 1-V1;r~ ;?v~,.~ D.c.. <br />/ <br />Address ofagmt: {S-6 7 /1-nder- A- E~ ~ MAl" 5-s7?-2. <br />Te1ephonenumberofagcnt: ~ Cf.!.""7j 717-' Dateofdisplay: f-<{-p' Time of display: "l::J.g-I()'J~_ <br />Location of display: l-~e.. '---~ ~l." ~~? Ie- " M,1/' <br />Mauner and place of slOrageoffueworkslpyrotechnic special effects prior to display: {3' ,. /''1 C F,.y..~~. <br />S~..A- 1'/1 t IfrF Iff ~a-'Z-,h- .,f- #'"ff. <br />Type & number offireworkslpyroChnic special effects to be discharged: I, 3 , ,. /, 'f C A~,. <br /> <br />MINNESOTA STATE LAW REQUIRES THAT THIS DISPLAY BE CONDUCfED UNDER THE DIRECI' <br />SUPERVISION OF A PYROTECHNIC OPERATOR CERTIFIED BY THE STATE FIRE MARSHAL. <br /> <br />NAME OF SUPERVISING OPERATOR: I'll rr~ CERTIFICATE NO.: O.n 7 <br /> <br />lunderstand d compI 'thall ~fth. 12----1, . andth - fthe- - th t?S'iand~ <br />an agree to y WI proVISIons 0 IS app IcatlOO C reqUlfements 0 ISSWDg au onty, <br />will ensure that the fireworkslpyrotechnic special elTects are discharged in a manner that wiD not endanger persons or <br />property 01" constitute a 1lUisaooe_ <br /> <br /> <br />app <br /> <br />on: <br /> <br />~- - hS-f7' <br /> <br />Required attaeblDeDD. <br /> <br />Bltachments must be included with this application: <br /> <br />1. Proof of a bond or certificate of insurancc in amount of Bl1east $ ~ ~ ~ <br />2. A diagram of the ground, or facilities (for indoor displays), at which the display win be held. This diagram <br />(drawn to scale or with dimensions included) must show the point at which the fireworkslpyrotechnic special <br />effects are to be discbargcd; the location of ground pieces; the location of all buildings, highways, streets, <br />communication lines and other possible overhead obstructions; and the lines behind which the audience will be <br />restrained. For proximate audience (e.g. indoor) displays, the diagram must also show the fallout radius for <br />each pyrotechnic device used during the display. <br />3. Names and ages of all assistants that will be participating in the display. <br /> <br />The discluuge of the listed fueworks on the date and at the location shown on this application is hereby approved, subject to <br />the following conditions, if any: <br /> <br />Signature of fire chief7county sheriff: <br /> <br />Date: <br /> <br />Signature ofissuing authority: <br /> <br />Dale: <br /> <br />31 <br />