Applicant's Company:
Event:
Event Date(s): Event Time(s):
Event Location/Address:
Setup Time and Date:
Inspection
Name of person conducting inspection:
Phone number:
Date and Time:
Written Permission or Notarized Hold Harmless Agreement
Must have written permission from Owner or if City Property must have notarized Hold Harmless Agreement
Attached Letter from Owner of Property or Authorized Representative to Hold Event
Attached Notarized Hold Harmless Agreement
Insurance
Provided Certificate of Insurance: Yes No
Aerial Shells and Pyrotechnic Materials
List Types:
Number:
Sizes:
Detailed Site Plan
Attached Site Plan
Dimensions of Discharge Site:
Included:
Parking Areas: Roadways:
Spectators' Viewing Areas: Trees:
Buildings: Telephone Lines:
Other Overhead Obstructions
City of Chandler Fire Department
Attached City of Chandler Fire Department Fireworks Supplement Personnel Form
Hand Deliver Applications To
Chandler Fire Department Chandler Fire Department
Attn: Virginia Holtzclaw Attn: Virginia Holtzclaw
Fire Prevention Bureau Fire Prevention Bureau
P.O. Box 4008, Mail Stop 801 151 E. Boston St.
Chandler, AZ 85244-4008 Chandler, AZ 85225
Mail Applications To
Applicant's Phone Number:
Applicant's Email Address:
FIREWORKS AND PYROTECHNIC DISPLAY
APPLICATION
Please complete all information; do not leave any spaces blank. Write N/A in spaces that do not pertain to your
event. Incomplete applications will not be processed.
Applicant's Name:
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