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Application For Permit To Sell Salable Fireworks At Retail Form - Alaska Department Of Public Safety Division Of Fire Prevention

DEPARTMENT OF PUBLIC SAFETY

OFFICIAL USE ONLY

PERMIT # _________________

DIVISION OF FIRE PREVENTION

Issue Date _________________

5700 East Tudor Road

Receipt # _________________

Anchorage, Alaska 99507-1225

APPLICATION FOR PERMIT TO SELL SALABLE FIREWORKS AT RETAIL

(Authority AS 18.72.020, 13 AAC 511.020, 1997 UFC Article 77 & 78)

Last Name

First Name

Middle Initial

Social Security Number

Company Name

Wholesaler Name & Wholesale License No.

Company Mailing Address

Wholesaler Mailing Address

City,

State

Zip

City,

State

Zip

__________________________________________

Telephone number(s)

Wholesaler telephone number(s)

The exact location of the site proposed to be used for the retail sale of salable fireworks. (Note requirements below)

________________________________________________________________________________________________

Per AS 18.72.020 (a) a policy or certified true copy of a policy of public liability and products liability insurance

provided by the wholesale company is attached. Expiration date of liability insurance is: __________

I, hereby, certify that the above statements made by me are true and correct to the best of my knowledge, and that I have

concealed no material facts relevant thereto. (The State of Alaska, Department of Transportation will not permit stand

to be located on State Highway Right-of-way, i.e. 150 feet from the centerline).

Signature of Applicant

Date

Subscribed and sworn to before me on this day ________ of _____________ , 19___

(SEAL)

Notary Public in and for

My Commission Expires

The fee for these permits is $10.00 and must be paid every TWO years. Your permit is ONLY valid during the dates of

your liability insurance. Please make checks payable to the State of Alaska and attach the following information:

1. Map of stand location; including construction and distance to any storage magazines or nearby buildings. The stand

must be 250 feet from residential or public assembly buildings, and 150 feet from the centerline of ANY state

highway. At least two exits must be provided, indicated on a drawing of the proposed stand.

2. A policy or certified true copy of a policy of public liability and products liability insurance of at least $200,000 for

bodily injury or death and at least $50,000 for property damage. The applicant must be the person named on the

insurance policy. FAX copies from the insurance companies will be accepted.

IF YOU NEED FURTHER INFORMATION, CONTACT MARIE COLLINS AT (907) 269-5625.

Application For Permit To Sell Salable Fireworks At Retail Form - Alaska Department Of Public Safety Division Of Fire Prevention

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