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APPLICATION FOR FIREWORKS PERMIT Fee: $30 . 00 <br /> Information Request: <br /> Date: 7—/g , 19 91 Application No. <br /> Name: ]i(rA-,/�A n+ op, Tn v �i� az, <br /> Address: 13 fS/ A-�4/��� Phone: 4/7,5 ,� 7-) <br /> T <br /> O o "'A' Sorem-d. L4; f+YG <br /> City: (.rid.-)/j A-T",¢ /n, ,Yry Zip: 5-1.5--- L7? / <br /> Location of Fireworks Display: yvp-y�t,7-,11._ C-acisv7ry d b. <br /> Organizations Handling Fireworks Display <br /> Co. Name: W,–yyT1„,,7'"h y Supervisor:,Tjm. 131 rad <br /> Address: �, ST ,/ „A w � Phone: 473 6 9 -s-s- (day) <br /> City: W VI ' --4-- 4A p/ Phone: (eve) <br /> VI <br /> Name of company where fireworks will be purchased:A ,o a {, e,�� <br /> Address: Phone: <br /> City: Zip: <br /> Reason or Purpose:STA}.T,rvv �51��"Tsvw. Code nvr„,,-1 Date of Use:( . rte. 6T.T-. 19 <br /> Type of Fireworks: ? .S p,-/J u'T e LC <br /> Insurance Coverage: Amount: <br /> Company: Copy of Insurance Certificate to <br /> be submitted with this application. <br /> I am aware of all applicable State and other laws regarding possession and <br /> use of fireworks and will abide by same. I also agree to hold the City of <br /> Orono harmless from all liabilities that may arise directly or indirectly <br /> from the shooting of fireworks aprpoved by the granting of this permit. <br /> cjPeA"---CLa: <br /> 2 <br /> );-je <br /> Signature o App icant <br /> Recommended: Approval Denial II ' � / <br /> Sul 4g & Fire In-/.1'rtor <br /> i <br /> Recommended: Approval Deni l /1/j 1 / <br /> Po,ic '� h - <br /> Approved: Yes No r )(2,/)A1)' <br /> City Administrator <br /> Office Use Only: <br /> Remarks: n Inspection Date: <br /> 9. 0 Y� <br />