Home Page: Notices
|
TOWN OF RICHMOND APPLICATION FOR FIREWORKS PERMIT APPLICANT: ______________________________________________________ Name of individual, group or organization RESPONSIBLE INDIVIDUAL AND RELATIONSHIP TO GROUP OR ORGANIZATION: __________________________________________________ ADDRESS: _______________________________________________________ PHONE: ______________________ _______________________ DATE (on or after which fireworks may be purchased): ____________________ TYPE AND QUANTITY OF FIREWORKS WHICH MAY BE PURCHASED AND USED: DATE OF PERMITTED USE: _______________________ TIME OF PERMITTED USE: _______________________ (e.g. 8:00 – 10:00 pm) ANTICIPATED NUMBER OF PEOPLE AT EVENT: ___________ NAME AND ADDRESS OF INDIVIDUAL WHO WILL OVERSEE DISCHARGING OF FIREWORKS: _______________________________________________________ QUALIFICATIONS/CERTIFICATION/LICENSE OF INDIVIDUAL (Attach copy of certificate from Pyrotechnics Guild International—required by Town Ordinances): _______________________________________________________________________ _______________________________________________________________________ LOCATION OF PERMITTED USE: _________________________________________ (Complete address) OWNER OF PROPERTY ON WHICH USE IS PERMITTED: ____________________ PHONE NUMBER OF OWNER: _________________ _________________ REQUIRED BOND OR INSURANCE AMOUNT: __________________________ (A copy of the bond or insurance certificate must accompany this permit application. Such bond or policy must name the Town of Richmond as an additional insured.) OTHER REQUIREMENTS (e.g. required presence of fire department personnel, safety precautions, etc.): _________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ By signing this permit application, the undersigned agrees to indemnify and hold harmless the Town of Richmond, its supervisors, employees, agents and assigns from any liability, costs (including attorney fees), cause of action, claim, suit, proceeding, damage, death or injury of whatever nature or kind resulting from or associated with the use of fireworks pursuant to this permit. By issuance of this permit, the Town of Richmond, its supervisors, employees, agents or assigns make no assurances of any kind as to the adequacy of any of the safety precautions specified herein to prevent injury to persons or property. SIGNATURE OF APPLICANT: _______________________ DATE: ___________ RECOMMENDATION OF FIRE DEPARTMENT PERSONNEL: Fire Department: _________________________________ DATE: ___________ Printed Name and Title: _____________________________________________ APPROVAL OF TOWN OF RICHMOND: SIGNATURE: _______________________________ DATE:_______________ Printed Name and Title: ________________________________ EXPIRATION DATE OF PERMIT: _________________________ (After this date no fireworks may be purchased or used pursuant to this permit.)