HomeMy WebLinkAboutAPPLICATION - 05-00075 - BYUI - Fireworks~°
~.,
. ,~~ CITY ~_
~° RE:XBLIR~
~'~qet~~~'~" AMERICA'S FAMILY COMFvCUNrrY
°OPERATIONAL PERMIT" APPLICATION PERMIT#:
$50.00 FEE PAID~NO PERMITAPPROVED:~/NO
BY: ~~a, t~ ~.~. ~~ DATE: ~ `~
Owner Inform/ation: Parcel Number:
Owner: ~/~/1/~~ ~ ~.,~ ~ Phone Number: ~J ~ ~~ 7~
Owner Mailing Address: ~~ /V. c~~~lr 7~FX , (~~Cr~ ,,.~/ ~~7~a
Property Address: ~J 7 iVs ~~~D ~~/1~ Cell/Office Number. ~~~ ~~~~~ " /~~~~Q
Business Name Where Work Will Be
Office Address:
Office Phone Number: ~~~ ~~yd Contact Person c~~ L~1~~'~f;'ontact Phone #: 7~J ~~
Name
Name of Business: rC~ ~ ~~ l"~/~®~~~1~~ ~~~ C'_,
Address: ~~ 7/ V. ~~~ ~ ~/~C~~~ , ~ ~~~~(J
ContactPerson:U~~~ GV~~~ PHONE NUMBER: CELL# 1'U~ ~~f~~
Parade Route /Assembly Location:
(Map required for Parades)
~/ -~
A CA SIG ATURE DATE
Rexburg, Idaho 83440 Fax: 208-359-3024
www.rexbura.org cdd@rexburg.org
j
o P.O. Box 280
Q !G ® ~~~ ~QQ~° 12 North Center Street
Rexburg, Idaho 83440
Phone (208) 359-3020
STATE OF IDAHO Fax (208) 359-3022
e-mail rexburg@srv.net
FIRE ~YORKS DISPLA Y PERIVIIT APPLICATION
Application for permit to operate a display of outdoor fireworks in conformance
with the adopted codes and ordinances of the City of Rexburg shall be made in writing on
forms provided by this city. All requested information must be provided, incomplete
applications will be denied. This display permit allows the discharge of fireworks by
qualified persons only. Completed applications must be received a minimum of seven (7)
days prior to the event.
Name of Applicant/Company: Ell'~T~ ~~%~~~~~j~~KS
Contact Person:
Contact Telephone Number ~~~~ /~J 7/ Cell: ~~~~ °~J~~
Name of organization applicant represents: ~~~"~`~"~
~ ~~~
Proposed Date and Time of Display: /~~~_~
Rain Date:
Name of Person Conducting display:
(Please provide copy of State license) ~lA~ ~~~. a/~~
Type, size and amount of fireworks to be discharged: (J~
Storage location of fireworks: ~~"~,~'~%j~~ ~~~ ~ ~~~Z~
Exact, location of display:
(Please provide a map of the area)
Owner of property where display is to be located: ,rj 1' U ~~~^~"
Phone:
Liability insurance covering event: (attach copy of policy)
Company: ~'(o.qN ,N~-Q41,F~,~]~olicy No: 7~~P~G~XK.//
Coverage Period:'y~-by ~d ~ -off?-~ Policy Limits: l,d4fl~ CSOO ~ o~
Name of Agent:.+~'p~ t, Qo~SSECL Agent Phone No: ~4-S~$~
Signature of Code Official verifying coverage Name of Insurance Co. Representative
Providing information
Consent of Property Owner:
UWe ~ ~V - ~A~'O ,owners of the above described
property, hereby expressly give my/our consent to the use of my/our property for the
event applied for in this application.
Signature of Property Owner Printed name
Address: 2c~ o G. lGc w~,tv a ~ ` Telephone: ~ 4 ~ `~<o t l S S
~ v r~ aF'o '~ 3 4(o b
If the display is to take place on property belonging to The Church of Jesus Christ
of Latter Day Saints, a letter of'authorization from a representative of the church shall be
provided with this application.
OTHER REQUIREMENTS:
1. A minimum of two (2) 2Al OBC fire extinguishers shall be present at the site
during the fireworks display.
2. A minimum of two (2) qualified persons shall supervise the actual firing at all
times during the display.
3. A copy of the approved permit must be on-site during the display.
4. If a bum ban or winds exceeding 20 miles per hour exist at the time of the display
the show will be cancelled.
My signature indicates that I understand and will comply with all requirements to
ensure a safe and legal discharge of fireworks.
~ J
`' a ~
~~
Signa e of Applicant Date
Apulicant check off list:
-This form filled out in its entirety -Copy of State License
-Certificate of Insurance -Detailed site plan
Payment of permit fee -Consent of property owner
Approved
Disapproved
Fire Department Representative
Approved
Disapproved
City Clerk
Approved _ Disapproved
Other
r•
:~ ~,__
^ Operating aviation facilities
Location:
^ Operating carnivals or fairs
Location:
Dates 8~ Times:
^ Organic coatings
T pes:
^ Places of assembly
Location:
Dates & Times:
^ Private fire hydrants
Loc n:
Pyrotechnic special eff cts material
Location: / 5~ G(!E5!~7~ h"~vT~~
^ Pyroxylin plastics
T es:
^ Refrigeration equipment
T es:
^ Repair garages/motor fuel dispensing
Location:
^ Rooftop heliports
Location:
^ Spraying or dipping
Location:
^ Storage of combustible fibers
Location:
T es:
^ Storage of scrap tires/etc.
Location:
^ Temp. membrane structures, tents, and
canopies
Location:
Date & Times:
^ Tire-rebuilding plants
Location:
^ UselStorage of compressed gases
Location:
T pes:
^ Waste handling
T es:
^ Wood products
T es:
Additional Information: