2016.07.05 CC Packet - Laserfiche WebLink

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G . 9 APPLICATION FOR OUTDOOR DISPLAY OF FIREWORKS/PYROTECHNIC SPECIAL EFFECTS Applicant instructions: This application must be completed and returned at least 15 days prior to date of display. Name ofapplicant (Sponsoring Organization): Wilson Tool Interntaional Address of applicant: 4902 Evergreen Pl. North Branch. MN 55056 Name of authorized agent of applicant: _Pyrotechnic Disnlav, Inc Address of agent: 9405 River Road SE. Clear Lake. MN 55319 Telephone number of agent: 320-743-6496 Ext. I Date of display: August 13, 2016 Time of display: _about 1 int Location of display: Hugo, Minnesota - please see attached site man Manner and place of storage of fireworks/pyrotechnic special effects prior to display: Delivery and storage in truck on day of displav Type & number of fireworks/pyrotechnic special effects to be discharged: I.3G product - up to 5 inch aerial shells and Multi -Shot Box Items & Candles Minnesota State law requires that this display be conducted under the direct supervision of a pyrotechnic operator eerlified by the State Fire Marshal. Name of supervising operator: Dylan Stanton Certificate No.: 0770 Required attachments. The following attachments nmst be included with this application: I. Proof of a bond or certificate of insurance in amount of at least S 5.000.000.00 _ 2. A diagram of the grounds at which the display will be held. This diagram (drawn to scale or with dimensions included) must show the point at which the fireworks/pyrotechnic special effects are to be discharged; the location of ground pieces; the location of all buildings, highways, streets, communication lines and other possible overhead obstructions; and the lines behind which the audience will be restrained 3. Names and ages of all assistants that will be participating in the display. Andy Saxe, Cert # 01015, 33 The discharge of the listed fireworks on the date and at the location shown on this application is hereby approved, subject to the following conditions, if any: I understand and agree to comply with all provisions of this application, MN Statute 624.20 through 624.25, MN State Fire Code, National Fire Protection Association Standard 1123 (2006 edition), applicable federal law(s) and the requirements of the issuing authority, and will ensure that the fireworks/pyrotechnic special effects are discharged in a manner that will not endanger persons or property or constitute a nuisance. Signature of applicant (or agent): Signature of Fire chief: Date of application: June 29, 2016 Date: Printed name of above official: Phone: Signature of issuing authority: Printed name of above official: Phone: