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k.'eiils p Bp' -W... n.neo <br />u +wake, MN 55025 <br />Appliant instmetians: <br />(FOA USE BY LOCAL JURISDICTIONS) <br />SAMPLE APPLICATION ,pF,gMtT <br />OUTDOOR PUBLIC FIREWORKS DISPLAY <br />LOW <br />"l�,_a K8ft18 (;jygr <br />L.akp MN <br />, <br />xxI <br />1. 'This application is for an outdoor Public fireworks display only and is not valyd for an '"door fireworks 3. This �luxt must is a compler� and returneda, least 1.5 ([µys prior to date of for an' display <br />3. Fee uapplication <br />and must be mile payable to <br />Name of Appficaat (Sponsoring Organiution): ��{9m <br />�9►►1er <br />Address of Applicu* <br />Name of Applicant's Authorized Agent: <br />Address of Agent: <br />Telephone NumberofAgent: �/� /r <br />teofDispky t`J 14 t <br />[.oration of Display; ty 7.,, .. ------------Timt of Display: _ t% <br />R <br />Manna and place ofstotage, of fireworks prior m display:I�CJ�' <br />Type and number of fireworks to be di <br />aahargea; <br />tU4 L.. 44 f"CC <br />MINNESOTA STATE LAW R <br />SUPERVISION OFA PYR EQIIIRES THAT THIS TO DISPLAY BE CONDUCTED UNDER THE D <br />CHNIC OP TOR CtERTtFiED BY THE STATE HtECr <br />Name of Supervising Operator: / V( i��nr,Q "REMAMHAL. <br />Requiredattachments. The — CettificateNo.:foliowngattaohments v <br />must be included with this lication <br />I . Proof ofa bond or certificate of Insurance in amount of at <br />2. 1ilst S __ t� 0(7 <br />( ` <br />fSuggrsradAmauxr. St.: miflian,ninimum. El.J milli wa minimwn brgtnntng,lal 1, <br />nclud� mus shay tai et which the display will be held. This diagram drown to <br />Y 005?) <br />location of all buildings, highwat which tbs fitetvorks arc to 6e dischar ( seek or with dimensions <br />fines behind wfiich.thaaudience will rust�imeed. mcaoon Jinos and def• the tacation of ground pisco$; the <br />3. Names and Possible overhead obstructions: and the <br />ages of all assistants thgt wrH be panrcipanng in the disph:y. <br />Tho discharge of the listed fireworks on the date and at iha ! <br />the folio wing conditions, if any: ovation shown on this application is hereby approved, Subject to <br />I anderata.1d and agree to comply with ai, <br />Code, National Fire Protection Assoraatic <br />the issuing authority, and will ensure that <br />or constitute nuisance <br />Signature of Applicant (or Allem). f <br />/, <br />Signature of Fite Chief/County Sherif_& <br />Signature of Issuing Authority: <br />Of <br />this a <br />1123 2 i% edition), <br />, . Statute 624.20 through'124.2.5, MN St uc Fire <br />{ edition), app}iceble federal law(s) and the rryuiretnents of <br />ks aro disclyrged in a manner that will not endanger, persons a prop <br />n Ad i4 <br />Data: T-/�/0/ <br />Date: <br />Date: <br />Revise! lune 2nna <br />