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Application Form For Permit To Use Dangerous Fireworks And Class "C" Fireworks In Excess Of 250 Pounds - Department Of Public Safety Division Of Fire Prevention Of Alaska

DEPARTMENT OF PUBLIC SAFETY

OFFICIAL USE ONLY

PERMIT # _________________

DIVISION OF FIRE PREVENTION

Issue Date _________________

5700 East Tudor Road

Verification _________________

Anchorage, Alaska 99507-1225

APPLICATION FOR PERMIT TO USE DANGEROUS FIREWORKS

AND CLASS “C” FIREWORKS IN EXCESS OF 250 POUNDS

(Authority AS 18.72.010, 13 AAC 51.010)

Pyrotechnic Operator’s: Last Name

First Name

M.I.

Social Security Number

Pyrotechnic Number

for

Company Name

Telephone Number

Mailing Address

City,

State

Zip Code

Wholesaler Name

Wholesale License Number

PROPOSED USE OF DANGEROUS FIREWORKS:

PROPOSED USE OF CLASS “C” FIREWORKS:

LIST ASSISTANTS FOR DISPLAY:

PHYSICAL LOCATION OF DISPLAY (including city):

DATE(S) OF PROPOSED DISPLAY:

Section 13 AAC 51.010 (b). There shall be attached to the application for a permit under this section a policy or

certified true copy of a policy of public liability insurance and products liability insurance coverage, including

both accident and occurrence in the amount of at least $1,000,000 for bodily injury and death and at least

$500,000 for property damage, provided by the applicant or his employer.

Signature of Applicant

Date

Subscribed and sworn to before me on this day ________ of _____________ , 19___

(SEAL)

Notary Public in and for

My Commission Expires

There are no fees for these permits. Please attach the following information:

Letter from the fire department in the proposed display area, stating that they are aware of display.

Map of fall-out area of proposed display including; shell size used, shoot area, spectator area, shell

fall-out area, all buildings and roads within the fall-out area in accordance to 1997 UFC 78.

An policy or certified true copy of a policy of public liability and products liability insurance

coverage.

Application Form For Permit To Use Dangerous Fireworks And Class "C" Fireworks In Excess Of 250 Pounds - Department Of Public Safety Division Of Fire Prevention Of Alaska

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