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Minnesota Department of Public Safety <br />State Fire Marshal Division <br />Application for Permit <br />Display of Indoor Fireworks / Pyrotechnic Special Effects <br />Revised 6/11 <br />Instructions: Complete this application, attach the non-refundable permit fee, proof of bond or insurance in the specified amount, a copy of the plan <br />for the use of pyrotechnics (see page 2 for the required contents of the plan), and submit to the address below at least 15 days prior to the date of <br />the display. If approved, permits will be issued to the Sponsoring Organization named on the application. <br />Minnesota Department of Public Safety <br />State Fire Marshal Division <br />444 Cedar Street, Suite 145 <br />St. Paul, MN 55101-5145 <br />Hours: 8:00 am to 4:30 PM, Monday – Friday <br />Name of Sponsoring Organization: <br />Address of Sponsoring Organization: <br />Name of Authorized Agent – Sponsoring Organization: <br />Address of Agent: <br />Phone Number of Agent: (W) (H) <br />Location of Display: <br />Date of Display: Time of Display: <br />Manner and Place of Storage of Fireworks / Pyrotechnic Special Effects Prior to Display: <br />Type and Number of Fireworks / Pyrotechnic Special Effects to be Discharged: <br />Minnesota Statute (MS 624.20) requires fireworks displays to be conducted under the direct supervision of a <br />fireworks operator certified by the Minnesota State Fire Marshal. <br />Name of Supervising Operator: MN Certificate Number: <br />Required Attachments: <br />1. Permit Fee (Non-Refundable): $150.00 (Cashiers or Certified Check Made Payable to the Minnesota Department of Public <br />Safety) Note: Inspection Fee - The sponsoring organization will be invoiced for the actual cost, including <br />personnel and travel costs, of conducting the inspection necessary for the issuance of a permit. <br />2. Proof of bond or insurance in the amount of $1.5 million minimum. <br />3. Plan for the use of pyrotechnics. (Required by NFPA 1126. See page 2 for required contents). Incomplete plans will be <br />rejected. <br />If this application is approved and a permit issued, I understand and agree to ensure that the indoor fireworks / pyrotech- <br />nics special effects display for which this application has been filed will be conducted in full compliance with Minnesota <br />Statute 624.20 - 25, the Minnesota State Fire Code, and National Fire Protection Association Standard 1126 (2006 Edition). <br />Signature of Authorized Agent: Date: