Request For Fireworks Display Permit - Town Of Camillus Page 2
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2(I)
Proof of Insurance or Bond (Minimum One Million Dollars). Please attach a copy of the
policy certificate or other proof of insurance or Bond.
(J)
For Indoor displays, in addition to the information provided above, include a written plan for
how you intend to use the pyrotechnics as required by the New York State Penal Law 405.10. That plan
shall be submitted at least five days prior to the performance and include:
In addition to the State Licenses and Certificates already included in this application, proof of Federal
•
ATF Licenses if required.
Proof of experience of the pyro technician in charge,
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Proof of experience with the types of devices being used and a description of duties of any authorized
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assistants,
Point of assemble of the pyrotechnic devices,
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Manner and place of storage of the pyrotechnic materials and devices,
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Material Safety Data Sheets (MSDA) for the pyrotechnic materials to be used,
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Certification that set, scenery, and rigging materials are inherently flame-retardant or have been treated
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to achieve flame retardancy,
Certification that all materials worn by performers in the fallout area during the use of pyrotechnic effects
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are inherently flame-retardant or have been treated to achieve flame retardancy,
For indoor displays attach a diagram of the area where the display will take place, showing location
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where the fireworks will be discharged from, the location of, and distance to the audience, the location of
sprinklers and the fallout radius for each pyrotechnic device used,
A copy of the approved permit and plan shall be kept on site and available for review,
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Any significant changes to the plan shall be approved prior to the performance.
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(K)
I attest that the information contained in this permit application is accurate, true and
complete to the best of my knowledge, and I understand that false statements made in this permit applica-
tion are subject to the applicable version of the NYS Penal Law.
______________________________________________________________________________
Signature of Applicant
Title
Date
OFFICIAL USE ONLY
_________________________________________________________________________________________________
Approved By
Title
Date
Revision Date 08/16/2012
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