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<br />Revised June 2011 <br />(FOR USE BY LOCAL JURISDICTIONS) <br /> <br />SAMPLE APPLICATION / PERMIT <br />OUTDOOR PUBLIC FIREWORKS DISPLAY <br /> <br />Applicant instructions: <br /> <br />1. This application is for an outdoor public fireworks display only and is not valid for an indoor fireworks display. <br />2. This application must be completed and returned at least 15 days prior to date of display. <br />3. Fee upon application is $_______________ and must be made payable to <br /> <br />Name of Applicant (Sponsoring Organization): <br /> <br />Address of Applicant: <br /> <br />Name of Applicant’s Authorized Agent: <br /> <br />Address of Agent: <br /> <br />Telephone Number of Agent: Date of Display: Time of Display: <br /> <br />Location of Display: <br /> <br />Manner and place of storage of fireworks prior to display: <br /> <br /> <br /> <br />Type and number of fireworks to be discharged: <br /> <br /> <br /> <br />MINNESOTA STATE LAW REQUIRES THAT THIS DISPLAY BE CONDUCTED UNDER THE DIRECT <br />SUPERVISION OF A PYROTECHNIC OPERATOR CERTIFIED BY THE STATE FIRE MARSHAL. <br /> <br />Name of Supervising Operator: _______________________________________________ Certificate No.: <br /> <br />Required attachments. The following attachments must be included with this application: <br /> <br />1. Proof of a bond or certificate of insurance in amount of at least $ _________________________________________ <br />(Suggested Amount: $1.5 million minimum) <br />2. A diagram of the ground at which the display will be held. This diagram (drawn to scale or with dimensions <br />included) must show the point at which the fireworks are to be discharged; the location of ground pieces; the <br />location of all buildings, highways, streets, communication lines and other possible overhead obstructions; and the <br />lines behind which the audience will be restrained. <br />3. Names and ages of all assistants that will be participating in the display. <br /> <br />The discharge of the listed fireworks on the date and at the location shown on this application is hereby approved, subject to <br />the following conditions, if any: <br /> <br />I understand and agree to comply with all provisions of this application, MN Statute 624.20 through 624.25, MN State Fire <br />Code, National Fire Protection Association Standard 1123 (2006 edition), applicable federal law(s) and the requirements of <br />the issuing authority, and will ensure that the fireworks are discharged in a manner that will not endanger persons or property <br />or constitute a nuisance. <br /> <br />Signature of Applicant (or Agent): ___________________________________________________ Date: _______________ <br /> <br />Signature of Fire Chief/County Sheriff: Date: <br /> <br />Signature of Issuing Authority: Date: ____________