3.3. SR 05-17-2004 - Laserfiche WebLink

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APPLICATION FOR DISPLAY OF FIREWORKS/PYROTECHNIC SPECIAL EFFECTS Applicant instructions: 1. This application must be completed and returned at least 15 days prior to date of display. Name of applicant (Sponsoring Organization):. Elk River Area Chamber of Commerce Address of applicant: 509 Highway 10, Elk River, MN 55330 Name of authorized agent of applicant: Melrose Pyrotechnics, Inc. Address of agent: 9405 River Road SE, Clear Lake, MN 55319 Telephone number of agent: 320-743-6496 Date of display: July 4, 2004 Time of display: approx. 10pm Location of display:.__ Elk River, Minnesota Manner and place of storage of fireworks/pyrotechnic special effects prior to display: Delivery and storage in truck on day of display Type & number of fireworks/pyrotechnic special effects to be discharged: 1.3G Aerial shells - up to 6 inch shells Minnesota State law requires that this display be conducted under the direct supervision of a pyrotechnic operator certified by the State Fire Marshal. Name of supervising operator: Charles Kuklok Certificate No.: O 0558 I understand and agree to comply with all provisions of this application 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 orcx~.sflnte a nuisance. / Signatureofapplicant(oragen; '~~(-O~t(',/2/v~-x~v~---~~ Dateofapplication: 4-30-04 Required attachments. The following at~chmpnts must be included with this application: 1. Proof of a bond or certificat{ of i~urance in amount of at least $ 5,000,000.00 . 2. A diagram of the grounds, or'~aeSlities (for indoor displays), at w~ch 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. For proximate audience (e.g. indoor) displays, the diagram must also show the fallout radius for each pyrotechnic device used during the display 3. Names and ages of all assistants that will be participating in the display. Paul Isder, 28 James Kingery, 27 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: Signature of fire chief/county sheriff: Date: Printed name of above official: Phone: Signature of issuing authority: (City clerk/county auditor) Date: Printed name of above official: Phone: