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Operational /Fireworks Display 4� REXB 1j, �O
Permit Application
19 East Main City of Rexburg
Rexburg, ID 83440 www.rexburg.org Phone: 208.359.3020
Fax: 208.359.3024
CITY O F
REXBURG
Ameri. Fa)nily Community
nut #: C 2
$50.00 FEE 1ftAI • YES/ O PERMIT APPROVED: YES /NO
t;
BY: DATE:
Application for permit to operate a display of outdoor fireworks in conformance with 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 7 days prior to the event.
Name of Applicant /Company:
Contact Person: _
Contact Telephone
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umber: ?� -�3 1 s - - 4 - 4 1 ( 9 Cell:
Name of Organization Applicant Represents: mit Qlr, G
Proposed Date and Time of Display: o o Q
Rain Date:
Name of Person Conducting Display:
(Please provide copy of State licenses
Type, Size and amount of fireworks to be discharged:
Storage location of fireworks:
Exact location of display: 2)M . 1 T Q-
(Please provide a map of the area)
1' i ko CI 01
Owner of property where display is to be located: ` L-1 r l ?.t )Z�IA 0 a
Phone: ? h pi - � CA �;Sr) t)
Liability insurance covering event: (attach copy of policy)
Company:
Coverage Period:
Name of Agent:
Signature of Code Official Verifying Coverage
Policy #:
Policy Limits: _
Agent Phone #:
11 LEO W
Name of Insurance C esentative Providing
Information APR 2 8 2008
CITY OF REXBURG
• •
t Consent of Property Owner
I /We , 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:
Telephone:
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 minim of two (2) 2A10BC fire extinguishers shall be present at the site during the fireworks display.
2. A minim 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 burn ban or winds exceeding 20 miles per hour exist at the time of the display the show will be
cancelled.
My sjgfiature inmate that I understand and will comply with all requirements to ensure a safe and legal discharge of
fire orks.
Al 28 1 d 8
tgclature Date
This form filled out in its entirety
Certifi e9f Insurance
Payment of permit fee
Copy of State License
Detailed site plan
Consent of property owner
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