Form Gid-273-Sf - Application For Permit To Conduct Outdoor Fireworks And/or Pyrotechnics Displays - State Of Georgia

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SAFETY FIRE COMMISSIONER

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER•COMPTROLLER GENERAL

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr., Suite 620, West Tower, Atlanta, GA 30334

404-656-9636

770-344-4854

bmathis@sfm.ga.gov

HAZARDOUS MATERIALS

Phone:

<> Fax:

<> E-mail:

APPLICATION FOR PERMIT TO CONDUCT OUTDOOR FIREWORKS

GID-273-SF JUN11

AND/OR PYROTECHNICS DISPLAYS

County of Display: _______________________

Georgia License Number: _____________________

(If Applicable)

Pursuant to the Rules and Regulations of the Safety Fire Commissioner, Chapter 120-3-22 and O.C.G.A. § 25-10, NFPA-1123, NFPA-1124,

NFPA-1126, application is hereby made for permit to conduct Proximate Audience Outdoor Fireworks and/or Pyrotechnics Displays.

NOTE: This application wiII not be processed if incomplete. Type or print with ballpoint pen.

Date: ________________

Date of Display: ________________

Time of Display: Start: _____________ End: _______________

APPLICANT INFORMATION

Name of Operator: _______________________________________________________________________________________________

Address: _______________________________________________________________________________________________________

City: ________________________ County: __________________________ State: ____ Zip: ____________ Phone: ________________

Company Name: ________________________________________________________________________________________________

Address: _______________________________________________________________________________________________________

City: ________________________ County: ________________________ State: ____ Zip: ____________ Phone: __________________

Exact Location of Fireworks/Pyrotechnics Display: ____________________________________________________________________

Property owner or representative granting permission for use of site and/or venue:

Name (Print): __________________________________________

Signature: __________________________________________

UN Classification of Products being used in Display: ___________________________________________________________________

Maximum quantity of fireworks and/or pyrotechnics to be used: ________________________________________________________

Person(s) conducting Display: _____________________________________________________________________________________

ATFE License Number: __________________________________________

Expires: ________________________________

THE DISPLAY SHALL BE CONDUCTED BY A COMPETENT OPERATOR TO BE DETERMINED BY THE PROBATE COURT OF SAID COUNTY:

No Persons other than the operator and his assistants shall be allowed within ___________ feet of the launching or detonation site.

Minimum Area of Fallout Required: __________________________

Fire Suppression Provided: ___________________________

Attachments to be provided by operator:

Proof of Insurance: A copy of valid comprehensive liability insurance in the amount of no less than as defined in O.C.G.A. § 25-10-3.2 (b)

shall be provided with this application. No permit will be considered unless this is provided.

Proof of Bonding: No permit will be considered unless this is provided.

Proof of Site Approval from the Local Fire Official: No permit will be considered unless this is provided.

Provide List to this Court of Competent Assistants: No permit will be considered unless this is provided.

I declare under the penalties of perjury that the foregoing statements in this application have been examined by me, and to the best of my

knowledge and belief are correct.

_________________________________________________________

Signature of Operator:

Sworn to and Subscribed before Me this _______ day of __________________, ________.

In the County of ___________________________, State of __________________________.

( Seal )

NOTARY

_________________________________________

___________________________

(Notary Public)

(My Commission Expires)

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this

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document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056.