Request For Fireworks Display Permit - Town Of Camillus

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REQUEST FOR FIREWORKS DISPLAY PERMIT
Town of Camillus
Ref: NY State Penal Law, Article 405.00
Application Date:_____________
(A)
Sponsor of the show
Name: _______________
Address: ____________________________________________
Phone: _________________ Contact: _________________
Display Company
Company Name: ________________________
Address: _____________________________________________
Phone: ________________________ Contact Person: ___________________
NYS Dept. of Labor Explosives License #: ____________ Expires: __________
Operator—Name of the certified pyro technician who will be in charge of the display
Name
Certificate #
Expires:
___________________
____________
_________
Authorized Assistants: Names of the individuals who are authorized by the operator to work on the show,
identified either by their certificate number and expiration date, if they are certified, or by their age and
phone number, if they are not certified.
Name
Certificate #
Expires:
___________________
____________
_________
___________________
____________
_________
(continue on separate sheet, if necessary)
(B)
Display Date/Time: _______________________________ Expected Duration: __________
(C)
Display Location: ____________________________________
(D)
Display Content:
______________________________________________________________________________
(E)
How will fireworks be stored prior to display: ________________________________________
(F)
Rain Date for display: _________________
(G)
If rained out how will fireworks be stored: ______________________________________
(H)
For outdoor displays not before a proximate audience, attach a diagram of the area where
the display will take place, showing location where the fireworks will be discharged from, the location of and
distance to: all the buildings, highways, lines of communications, location of the audience, trees, overhead
obstructions or other structures or devices that could be affected by the display or fallout from it.
Revision Date 08/16/2012

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