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7.a)1) ApplicationNOV/05/2014AED 05:48 AM PAR Systems FAX No, P.002 City of Scandia Fire Department 15040 Scandia Trail N Date: All —VA.3L Scandia, MIN 55073 Permit No: m S❑ n o[ aFax 651.433.6112 ': a'�kG%Js�l�,®m9lr'��tJ "f� l°t �zC�igrlis?!'�if rl4P(7jit�r,771 Agent Name: State )1' Zip. Zip Code: kd 30y Suite: Zip Code: Type and number of fireworks/pyrotechnic special effects to be discharged: 1 3 i ncx 1.4 Gq kA i fevaS Manner and place of storage of fireworks/pyrotechnic special effects to be discharged: .fie I ierE u e� S I1 5 � rrcP i n i -!a r 1�rr Display Fee; A. Flat Permit Fee: $100,00 B. State Surcharge: (.0005 x permd fee) Total A + B Make check payable to City of Scandia MINNESOTA STATE LAW REQUIRES THAT THIS DISPLAY BE CONDUCTED UNDER DIRECT SUPERVISION OF A PYROTECHNIC OPERATOR CERTIFIED BY THE STATE FIRE MARSHAL Name of Supervising Operator: 1/0 -irk 611 .Fcw CenificationNo,; b5 f Application Submittal Must Include: 1. Names and ages of all assistants that will be participating In the display. 2. Proof of a polloy of public general liability, bodily injury and property damage insurance, minimum amount of one million dollars ($1,000,000). The City of Scandia shell be named as an additional insured. 3. A diagram of the grounds at which the display will be held. The diagram must show the point at which the special effects are to be discharged; location of the ground places; location of buildings, highways, streets, communication ones and other possible overhead obstructions; fines behind which the audience will be restrained. hereby apply for this penult and I acknowledge that the information above Is complete and accurate; that the work will be done in accordance with the ordinances of the City of 5oandia and with the Minnesota State Flre Code; (hat I will ensure that the /irawarke/pyrotechnics special effects are discharged In a manner thatwill not endanger persons or property; that I understand this is not a permit but an application for a permit and work is not to start without a permit: that the work will be In accordance with the approved plans, specillcations and codes. Periodic and/or a final inspection of this work ie required by the Minnesota State Fire Code. It is the responsibility of the applicant to call the Scandia Fire Dept at 651.433.4383 to schedule an Inslpecit n prior occupancy and/or use. 1 Applicant or Agent Signature:/rsr/K Date: (v o V S- 2 O I &( Office Use: Required Inspections: I]Site Permit Approved By: Date: Entered: Issued: