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Application for Permit to Display Pyrotechnics (Application must be submitted 15 days prior to the date of the intended display) Submit To: City of Albany – Department of Fire & Emergency Services 26 Broad Street Albany, NY 12202 Name of Sponsoring Organization: Address: Phone: Company Performing Display: Address: Phone: Technician: Address: Phone: Location of Display: Date of Display: Time of Display: Duration of Display: Fire Suppression Needs or Fire Suppression Provided: The following MUST be provided in order for this to constitute a completed application: 1. Evidence of Financial Responsibility, including Insurance Carrier, Amount of Coverage (one million dollars minimum), policy number and policy holder (City of Albany must be additionally insured). 2. For outside displays, a diagram of the grounds on which the display is to take place showing the point at which the display is to be discharged, the location of all buildings, highways, and other lines of communication, the lines behind which the audience will be restrained, and the location of all trees, telegraph or telephone lines, or overhead obstructions. 3. For indoor displays, a diagram of the structure in which the display is to be held showing the point or points at which the displays will be discharged, proximity to all stage and structural appurtenances and their combustibility, and proximity to any person or persons whether members of the audience or part of the performance or display. 4. A description of the number, quantity and types of materials to be discharged and method and materials used to ignite them. 5. A description of the manner and place of storage including the locations of appropriate signage. 6. A description of the person or persons who are to do the actual discharging of the display, including age, experience, physical characteristics, any current licensing or memberships in related associations, and information regarding the rejection, suspension or revocation of any previous license. 7. $75.00 application fee (made payable to the City of Albany) I HEREBY CERTIFY THAT I HAVE READ THE INSTRUCTIONS AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF LAWS AND ORDINANCES COVERING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR NOT AND I WILL ALSO ALLOW ALL INSPECTORS TO ENTER THE PREMISES FOR THE REQUIRED INSPECTIONS. THE GRANTING OF A PERMIT DOES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULATING SAID DISPLAY. Signature of Date Official Use Only Approved Not Approved By: Date: