Fillable APPLICATION FOR FIREWORKS DISPLAY PERMIT OFFICE OF CODE (Incorporated Village of Sag Harbor)

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APPLICATION FOR FIREWORKS DISPLAY PERMIT OFFICE OF CODE (Incorporated Village of Sag Harbor)

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The APPLICATION FOR FIREWORKS DISPLAY PERMIT OFFICE OF CODE (Incorporated Village of Sag Harbor) form is 2 pages long and contains:

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  • 52 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Incorporated Village of Sag Harbor

BROWSE INCORPORATED VILLAGE OF SAG HARBOR (NY) FORMS

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OVER
OFFICE OF CODE ENFORCEMENT/ BUILDING DEPARTMENT
VILLAGE OF SAG HARBOR
55 MAIN ST.
PO BOX 660
SAG HARBOR, N.Y. 11963
631-725-2804
631-725-4852 fax
kpayne@sagharborny.gov
APPLICATION FOR FIREWORKS DISPLAY PERMIT
EVENT SPONSOR EXACT EVENT LOCATION
NAME
_________________________________
LOCATION
__________________________________
ADDRESS
_________________________________
ADDRESS
__________________________________
CITY/STATE/ZIP
_________________________________
CITY/STATE/ZIP
SAG HARBOR, NY 11963
PHONE
_________________________________
PHONE
__________________________________
EVENT INFORMATION
DATE AND TIME OF EVENT:_________________________
RAIN DATE AND TIME:_______________________________
RESPONSIBLE PERSON
1
OPERATOR
2
NAME
_________________________________
NAME
_________________________________
ADDRESS
_________________________________
ADDRESS
_________________________________
CITY/STATE/ZIP
__________________________
CITY/STATE/ZIP
_________________________________
PHONE
_________________________________
PHONE
_________________________________
BATF EXPLOSIVES
LICENSE/PERMIT #
_________________________________
LARGEST DIAMETER SHELL TO
BE DISCHARGED:
NO. OF SHELLS TO
BE DISCHARGED:
NUMBER OF
MONITORS
3
:
NUMBER OF
ASSISTANTS
4
:
SHELLS OVER 8” IN DIAMETER MUST BE FIRED ELECTRONICALLY FROM
BEHIND A BARRICADE OR FROM A MINIMUM DISTANCE OF 75 FEET
.
DISPLAY WILL BE FIRED:
MANUALLY ELECTRONICALLY
ALL PERSONS SHALL HAVE PHOTO IDENTIFICATION ISSUED BY THE PYROTECHNIC COMPANY
AND VALID GOVERNMENT ISSUED PHOTO IDENTIFICATION
1
RESPONSIBLE PERSON: An individual who has the power to direct the management and policies of the operator pertaining to explosive materials.
2
OPERATOR: The person with overall responsibility for the safety, setup, and discharge of an outdoor fireworks display.
3
MONITOR: A person designated by the sponsors of the display whose sole responsibility is to keep the audience in the intended viewing area and out
of the discharge site and fallout area.
4
ASSISTANT: A person who works under the direction of the operator to put on an outdoor fireworks display.
C:\Users\czaino\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\TPZS3A6N\Fireworks Display Permit new ATTACHMENT 2.doc
ASSISTANT NAME
ASSISTANT NAME
DATE OF BIRTH
DATE OF BIRTH
LICENSE NO.
LICENSE NO.
ASSISTANT NAME
ASSISTANT NAME
DATE OF BIRTH
DATE OF BIRTH
LICENSE NO.
LICENSE NO.
ASSISTANT NAME
ASSISTANT NAME
DATE OF BIRTH
DATE OF BIRTH
LICENSE NO.
LICENSE NO.
PLEASE INDICATE THE MANNER AND PLACE OF STORAGE OF SUCH FIREWORKS PRIOR TO DELIVERY TO THE OUTDOOR FIREWORKS
DISPLAY SITE:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
ALL APPLICATIONS MUST BE SUBMITTED 30 DAYS PRIOR TO DATE OF DISPLAY
CHECK BOXES NEXT TO ITEMS SUBMITTED WITH THIS APPLICATION:
DIAGRAM OF THE GROUNDS, DEPICTING WHERE FIREWORKS ARE TO BE DISCHARGED, LOCATION OF ALL BUILDINGS,
HIGHWAYS AND OTHER LINES OF COMMUNICATION, THE LINES BEHIND WHICH THE AUDIENCE IS TO BE RESTRAINED, AND THE
LOCATION OF OTHER POSSIBLE OVERHEAD OBSTRUCTIONS
SCHEDULE OF TYPE, QUANTITY AND SIZE OF ALL SHELLS TO BE DISCHARGED
PROOF OF LIABILITY INSURANCE FROM THE SPONSOR
PROOF OF LIABILITY INSURANCE FROM THE EMPLOYER
PROOF OF WORKMAN’S COMPENSATION FROM THE EMPLOYER
PROOF OF DISABILITY INSURANCE FROM THE EMPLOYER
IF ALL BOXES ARE NOT CHECKED THIS APPLICATION IS INCOMPLETE
DISPLAYS SHALL COMPLY WITH PL 405 AND NFPA 1123
EVENT SPONSOR
PYROTECHNIC CONTRACTOR
SIGNATURE:
SIGNATURE:
NAME:
NAME:
DATE:
DATE:
DEPARTMENT USE
ONLY
FIRE CHIEF
⃞
APPROVED
⃞
DENIED
CODE OFFICER
⃞
APPROVED
⃞
DENIED
C:\Users\czaino\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\TPZS3A6N\Fireworks Display Permit new ATTACHMENT 2.doc
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APPLICATION FOR FIREWORKS DISPLAY PERMIT OFFICE OF CODE (Incorporated Village of Sag Harbor)

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Completed 16 July 2020

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