06.g Display of Fireworks Permit ApplicationCity of Scandia
Fire Department
15040 Scandia Trail N Date:
Scandia, MN 55073 Permit No:
Business 651.433.4383
Fax 651.433.5112
DISPLAY OF FIREWORKS PERMIT APPLICATION
Applicant Name:_______________________________________________________________Phone:_________________________
Applicant Address:________________________________________________________________Suite:__________________________
City:_____________________________________State________________________________Zip Code:_______________________
Authorized Agent Name: __________________________________________________________Phone:_________________________
Agent Address:___________________________________________________________Suite:__________________________
City:_____________________________________State________________________________Zip Code:_______________________
Type and number of fireworks/pyrotechnic special effects to be discharged:______________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Manner and place of storage of fireworks/pyrotechnic special effects to be discharged:_____________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Display Location:_____________________________________________________Date:_______________Time:______________
Fee:
A. Flat Permit Fee: $100.00 $_____________________
B. State Surcharge: (.0005 x permit fee)$_____________________
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:___________________________________________________Certification No.:_______________
Application Submittal Must Include:
1. Names and ages of all assistants that will be participating in the display.
obstructions; lines behind which the audience will be restrained.
Applicant or Agent Signature:_______________________________________________Date:___________________________
Office Use:
Required Inspections: Site
Permit Approved By:______________________________Date:_____________Entered:_________Issued:_________
I hereby apply for this permit 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 Scandia and with the Minnesota State Fire Code; that I will ensure that the fireworks/pyrotechnics special effects are
discharged in a manner that will 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, specifications and codes.
Periodic and/or a final inspection of this work is 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 inspection prior to occupancy and/or use.
2. Proof of a policy of public general liability, bodily injury and property damage insurance, minimum amount of one million dollars ($1,000,000). The
City of Scandia shall 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 pieces; location of buildings, highways, streets, communication lines and other possible overhead