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3. 

6. Permit Application Display of Fireworks

   Submit no less than five (5) working days prior to the event.

8. EVENT INFORMATION

10. Event Name
12. Event Date(s)
    Event Date(s) Start Date

    Event Date(s) Start Time

    —

    Event Date(s) End Date

    Event Date(s) End Time
14. Event Location

16. APPLICANT

18. Name of Person Requesting Permit
20. Applicant's Address
21. Applicant's E-mail Address
23. Applicant's Day Phone
24. Applicant's Cell Phone
26. Copy of the Utah State "Display Operator's License" who is responsible for display set-up, firing, and take-down/disposal must be included.*
27. Contact Phone for Person responsible for display set-up, firing, and take-down/disposal:

29. INSURANCE

    Financial responsibility for the fireworks display is required.

31. Submit verification of insurance to the fire department by uploading a certificate of insurance for at least $1,000,000 liability insurance naming the City of Bluffdale as "Additionally Insured."*
32. Insurance Company Name

34. SITE PLAN

    A site diagram must be submitted. Diagram to include (reasonable to scale and legible): 

    • Diagram of the location at which the display will be conducted
    • Diagram of the site from which fireworks will be sidcharged
    • The location of Lines behind which the audience will be restrained
    • Spectator viewing area
    • Parking areas
    • Fallout area
    • Associated separation distances and structures shall be illustrated on the site plan
36. Site Plan Diagram*

38. SIZE AND TYPE OF FIREWORKS USED

40. Type
    -- Select One --CakesShellsOther
41. Quantity
42. Size
43. Do you have more fireworks to report?

    1. Yes
    2. No
45. Type
    -- Select One --CakesShellsOther
46. Quantity
47. Size
48. Do you have more fireworks to report?

    1. Yes
    2. No
50. Type
    -- Select One --CakesShellsOther
51. Quantity
52. Size
53. Do you have more fireworks to report?

    1. Yes
    2. No
55. Type
    -- Select One --CakesShellsOther
56. Quantity
57. Size
58. Do you have more fireworks to report?

    1. Yes
    2. No
60. Type
    -- Select One --CakesShellsOther
61. Quantity
62. Size
63. Do you have more fireworks to report?

    1. Yes
    2. No
65. Type
    -- Select One --CakesShellsOther
66. Quantity
67. Size
68. Do you have more fireworks to report?

    1. Yes
    2. No
70. Type
    -- Select One --CakesShellsOther
71. Quantity
72. Size
73. Do you have more fireworks to report?

    1. Yes
    2. No
75. Type
    -- Select One --CakesShellsOther
76. Quantity
77. Size
78. Do you have more fireworks to report?

    1. Yes

    If you have more fireworks to report, please contact Lance Nielson at lnielson@bluffdale.com. 

80. FEES

    Firework events require fire department stand-by or "Fire Watch." Unless approved otherwise, costs associated with fire watch will be invoiced to the responsible party listed above. Resource needs will be based on the size of the event, weather, proximity to dry fuels, etc. and will be determined by the Fire Chief or his designee.

    Firework Permit: None

    Fire Watch: $150/Type 1 engine; $65/Type 6 engine; maximum of $500 per event.

82. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
84. Electronic Signature
85. Date
    Date
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field