Free 01617.FH11 - Indiana

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APPLICATION FOR PERMIT SUPERVISED PUBLIC DISPLAY OF FIREWORKS
State Form 1617 (R5 / 3-09) Approved by State Board of Accounts, 2009

DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE & BUILDING SAFETY FIRE & BUILDING CODE ENFORCEMENT 302 West Washington Street, Room E241 Indianapolis, IN 46204 Telephone: (317) 232-2222

NOTE:

Failure to file a legible, properly completed application may result in the application being rejected.
Permit number Telephone number

The fee for the Supervised Public Display of Fireworks permit is $69.00.
Name of applicant Address of applicant (number and street, city, state, and ZIP code) E-mail address

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If applicant is a corporation, give name, address and telephone number of the following:
Name of President Address of President (number and street, city, state and ZIP code) Name of Secretary Address of Secretary (number and street, city, state and ZIP code) Date on which display is to be held (month, day, year) Exact location planned for display to be held County Number and kinds of fireworks to be discharged City Street Time of day when display is to be held Telephone number Telephone number

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Manner and place of storage of such fireworks prior to the display

Draw a diagram of the grounds on which the display is to be held, showing the point at which the fireworks are to be discharged, the location of all buildings, highways and other lines of communication, the lines behind which the audience will be restrained and the location of all nearby trees, telegraph or telephone lines or other overhead obstructions.

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The proposed display will conform with all laws of the State of Indiana and all regulations of the State Fire Marshal of Indiana.
Signature of applicant Date signed (month, day, year)

Approved by: (signature of Fire Chief)

Date signed (month, day, year)

Address of fire department (number and street, city, state, and ZIP code)

Telephone number

Fax number

E-mail address of fire department

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NOTICE TO APPLICANT

If a permit is issued pursuant to your filing this application with this office, said permit will be returned to the local fire chief and you will then obtain said permit by contacting the fire chief and posting a certificate of insurance. You will note that the minimum certificate of insurance by law is $10,000: however, the local fire chief may require a larger amount if in his judgment the situation requires it. Your application must be filed with the Department of Homeland Security office at least fifteen (15) days prior to the date of the proposed display. Under IC 22-11-14-2, the application shall be accompanied by a brief resume of the fireworks display operators or operators experience in the following: 1. Preparation of the display, 2. Igniting or discharging of fireworks, 3. Implementing emergency procedures, 4. Disposal of unfired or defective fireworks. This should include years of experience and legitimate training received.

NOTICE TO FIRE CHIEF

Upon receipt of such application, the Chief of the Fire Department shall make, or cause to be made, an inspection of the site of the proposed display for the purpose of determining whether the provisions of these regulations are complied with in the case of the particular display. Being satisfied that the display is properly lawful, the Chief of the Fire Department shall endorse the application, stating that he approves the display as being in conformance with all parts of the law and with these regulations.

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