2. APPLICATION & PERMIT TO DISPLAY FIREWORKS FOR ENTERTAINMENT PURPOSES*
   The fee is $100.00
3. 1. This is part of an Event Packet
   2. This is NOT part of an Event Packet
5. Organization*
7. Permit Holder's Name*
9. Permit Holder's Address*
   Include City/State/Zip
11. Permit Holder Phone Number*
12. Permit Holder Cell Number*
14. Permit Holder Email*
16. On Site the Day of Contact Name*
17. On Site the Day of Contact Phone*
    Preferably cell phone.
19. Date on and after which fireworks may be purchased:*
    Date on and after which fireworks may be purchased:
21. Type and quantity of fireworks which may be purchased*
23. Date of Event*
    Date of Event
24. Time of Event*
    Time of Event Start Time

    —

    Time of Event End Time
25. Location of Event*
27. Where is your water source?*
    Include all possible water sources and/or if you have additional mean to put out a fire.
29. Upload
    Use this section to upload your certificate of insurance and/or your fireworks type and quantity breakdown. Your permit will not be approved without these items.
31. *The fireworks display will be authorized by the Lake Country Fire & Rescue Department, Delafield Police Department and Mayor, and based on the following criteria:
    1. The Lake Country Fire & Rescue Department Fire Chief or his/her designee will inspect the location/display/detonation area and grounds prior to the display of fireworks.
33. 2. Proof of indemnity bond and/or adequate liability insurance shall be provided, $1,000,000. A true copy of the Certificate of Insurance is attached indicating that the Municipality, Lake Country Fire & Rescue Department and applicable associations, recreations or committees formed by the municipality to organize the “Event” named as additional insured on all liability policies.
35. 3. I agree to release, indemnify, and hold harmless the City of Delafield from and against any loss, damage of liability, including attorney’s fees and expenses, incurred by the latter and their respective employees, agents, volunteers, or other representatives arising out of or in any manner relating to the manufacture, installation, firing or disassembly of any pyrotechnic equipment or device and/or the supervision and presentation thereof.
37. By Submitting this form, you have read and understand the information in this application and will adhere to all rules and regulations set forth by the City of Delafield.
41. Office Use Only
43. L.C.F.R. Fire Chief
    Signature/Date
44. Police Chief
    Signature/Date
46. Mayor
    Signature/Date
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field