Fire and Life Safety Program

Temporary heating equipment temporary heating devices

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Unformatted text preview: _______________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Manner and place of storage prior to discharge: __________________________________________________________________________________ __________________________________________________________________________________ Supplier of fireworks and Country of origin: ________________________________________________ Financial Responsibility: ______________________________________________________________ == FIRE AND LIFE SAFETY PROGRAM Bonding Corporation or Insurance Company: ______________________________________________ Address: ___________________________________________________________________________ (Street Number and Name, City, State, and Zip Code) Amount of Bond or Insurance: ____________________ (to be set by municipality) FIVE-YEAR RECORD OF ACCIDENTS Year Losses Claims Description REFERENCES List the name, title, address, and telephone number of three persons for whom you have performed pyrotechnic discharges in the past five years. 1. Name: ____________________________________ Title: _______________________________ Organization: _______________________________ Telephone Number: ___________________ Address: ________________________________________________________________________ (Street Number and Name, City, State, and Zip Code) 2. Name: ____________________________________ Title: _______________________________ Organization: _______________________________ Telephone Number: ___________________ Address: ________________________________________________________________________ (Street Number and Name, City, State, and Zip Code) 3. Name: ____________________________________ Title: _______________________________ Organization: _______________________________ Telephone Number: ___________________ Address: ________________________________________________________________________ (Street Number and Name, City, State, and Zip Code) Sen...
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