Full Text
MABAS Division 41 McLean County Fire Chiefs Assn. APPLICATION FOR PERMIT FOR SUPERVISED DISPLAY OF FIREWORKS We hereby make application for a permit to conduct a display of fireworks on the: Day of Organization/Person Name & Address Said Display To Be Held Firm Providing Fireworks (Name & Address) IF THE DISPLAY IS A PYROTECHNIC DISPLAY: Firm / Lead Pyrotechnic Operator (Name & Address) Lead Pyrotechnic Operator State License # (Attach copy of Illinois Pyrotechnic License) Attach a list of Fireworks to be discharged. Where will Fireworks be stored prior to Has Liability Insurance been obtained for $1,000,000 or more? Yes No (copy must be provided) IF THE DISPLAY IS A CONSUMER DISPLAY: has received training from of the Fire Department, approved by the Office of the Illinois State Fire Marshall, to be a Consumer Operator. Attach a list of Fireworks to be discharged. Where will Fireworks be stored prior to Has Insurance been obtained for bodily injury and property damage for $100,000 or more? Yes No (Copy must be provided) All Accidents Must Be Reported To The Office Of The State Fire Marshal Within Thirty-Six (36) Hours of Any Occurrence. I UNDERSTAND AND AGREE THAT I MUST ALSO OBTAIN A FIREWORKS DISPLAY PERMIT FROM THE MCLEAN COUNTY CLERK IF THE DISPLAY IS LOCATED OUTSIDE OF A CITY, TOWN OR VILLAGE. Applicants Signature Date of Birth Typed or Printed Names Phone Applications MUST be submitted at least 15 days prior to the date of occasion. NOTE: Attach a diagram of display site, Copy of Insurance Papers, List of Fireworks to be ignited when application is submitted. ---PAGE BREAK--- ALL applicants are subject to a criminal background check as a condition to the issuance of the permit. This application will be approved only after all applicable forms are received and the proposed site has been inspected by the Chief (or their designee) of the Fire Department in which the display is to be held, and all are in compliance with the Fireworks Regulation Act (45 ICLS 35) (For Fire Department use only) Is Found To Be A Competent Individual And Is Hereby Designated As The LEAD OPERATOR And Is Authorized To Handle And Supervise Said Display Of Fireworks. Approved When Signed And Dated By Authority Having Jurisdiction. Date Issued Fire Chief FIREWORKS SITE INSPECTION REPORT LOCATION Date Of Inspection Is Distance To Any Fire Hydrant Or Water Supply More Than 600 Feet? Yes No Is Display Area Clear Of All Overhead Obstructions? Yes No Have Provisions Been Made To Keep The Public Out Of The Display Area? Yes No Is There A Hospital, Nursing Home Or Other Institution Within 600 Feet? Yes No Have Provisions Been Made For On Site Fire Protection During Display? Yes No This Display Site Has Been Determined Not To Be Hazardous To Property Or A Danger To Any Person Or Persons. Fire Chief (or their designee) Fire Department or Fire Protection District Where Display is to Occur