Free 42235.FH11 - Indiana

APPLICATION FOR AMUSEMENT ENTERTAINMENT PERMIT
State Form 42235 (R5 / 1-08) Approved by State Board of Accounts, 2008

Return this completed form to: DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE SAFETY - PERMIT DIVISION 302 West Washington Street, Room E241 Indianapolis, Indiana 46204

FOR OFFICE USE ONLY
Permit number Receipt number

Reset Form
Type of facility Name of facility Address of facility (number and street, city, state, and ZIP code) Specific room or floor number Closest intersecting street or road Description of facility

FACILITY INFORMATION Theater Assembly Hall Dance Hall Roller Rink Night Club Lodge Hall
City

Cabaret Carnival Fair

Special Event Gymnasium
County

Other (specify) __________________

Direction from intersection

North APPLICANT INFORMATION
Type of applicant Name of applicant

South

East

West

Telephone number

Owner

Operator

Lessee

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)

Address of applicant (number and street, city, state, and ZIP code) If incorporated, name of principal officer of corporation Name of person to contact for inspection Address of contact person (number and street, city, state, and ZIP code) Responding fire department Address of fire department (number and street, city, state, and ZIP code) Telephone number

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PERMIT REQUEST INFORMATION
Type of permit request Name of event

Special Event Endorsement
Date of event (month, day, year)

Annual Event
Hours of event Intended occupant load

If Special Event Endorsement, existing operating permit number

APPLICATION CERTIFICATION I, or we, ________________________________________________, hereby certify, under penalty of perjury, that the information contained in this application is true and accurate to the best of my knowledge and belief and that the operation of the place of amusement or entertainment or events described above will conform in every respect and at all times with the laws, rules, and regulations of the Fire Prevention and Building Safety Commission and will not be used for other purposes except as herein stated.
Signature Date (month, day, year)

PERMIT FEES Fees are based on occupancy load, effective September 30, 2006. 1 - 99 persons 100 - 499 persons 500 - 999 persons 1,000 - 4,999 persons 5,000 - 9,999 persons 10,000 persons or more Special Event Endorsement FOR OFFICE USE ONLY
Date permit issued (month, day, year) Date of reinspection (month, day, year) Date of inspection (month, day, year) Type of permit Fee amount / year of permit

$99.00 $134.00 $168.00 $203.00 $237.00 $272.00 $99.00

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