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First Name *
Last Name *
Phone *
Email *
Location *
Date/Time of Pyrotechnics *
Name of Pyrotechnics Company *
Name of Insurance Company *
Please attach contractor Certificate of Liability Insurance
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List of all Safety Equipment that will be present at time of activity: *
I hereby certify that I am the owner or authorized agent for the abovementioned property listed for a pyrotechnics event. All pyrotechnics will be in accordance with Chapter 33, Explosives and Fireworks, exclusively sections 3301.2.3 and 3301.2.4.2 of the International Fire Code. Applicant Signature: