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Get IN SF 42235 2010-2021

Reset Form APPLICATION FOR AMUSEMENT ENTERTAINMENT PERMIT FOR OFFICE USE ONLY Return this completed form to DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE SAFETY - PERMIT DIVISION 302 West Washington Street Room E241 Indianapolis Indiana 46204 State Form 42235 R6 / 2-10 Approved by State Board of Accounts 2010 Permit number Receipt number INSTRUCTIONS 1. Include an updated floor plan with this application* 2. If claiming exempt status include a valid 501c letter with this application* FACILITY INFORMATION Type of facility Theater Assembly Hall Dance Hall Roller Rink Night Club Lodge Hall Cabaret Carnival Fair Special Event Gymnasium City Name of facility Other specify County Address of facility number and street city state and ZIP code Specific room or floor number Description of facility Closest intersecting street or road Direction from intersection North South East West Type of applicant Owner Name of applicant Operator Telephone number Lessee Address of applicant number and street city state and ZIP code If incorporated name of principal officer of corporation Name of person to contact for inspection E-mail address Address of contact person number and street city state and ZIP code Responding fire department Address of fire department number and street city state and ZIP code PERMIT REQUEST INFORMATION Type of permit request Name of event Date of event month day year Annual Event Hours of event Intended occupant load APPLICATION CERTIFICATION I or we hereby certify under penalty of perjury that the information contained in this application is true and accurate to the best of my knowledge and belief and that the operation of the place of amusement or entertainment or events described above will conform in every respect and at all times with the laws rules and regulations of the Fire Prevention and Building Safety Commission and will not be used for other purposes except as herein stated* Signature Date month day year PERMIT FEES Fees are based on occupancy load effective September 30 2006. 1 - 99 persons 500 - 999 persons 10 000 persons or more 99. 00 134. 00 168. 00 203. 00 272. 00 Date permit issued month day year Date of reinspection month day year Date of inspection month day year Type of permit Fee amount / year of permit 20. Include an updated floor plan with this application* 2. If claiming exempt status include a valid 501c letter with this application* FACILITY INFORMATION Type of facility Theater Assembly Hall Dance Hall Roller Rink Night Club Lodge Hall Cabaret Carnival Fair Special Event Gymnasium City Name of facility Other specify County Address of facility number and street city state and ZIP code Specific room or floor number Description of facility Closest intersecting street or road Direction from intersection North South East West Type of applicant Owner Name of applicant Operator Telephone number Lessee Address of applicant number and street city state and ZIP code If incorporated name of principal officer of corporation Name of person to contact for inspection E-mail address Address of contact person number and street city state and ZIP code Responding fire department Address of fire department number and street city state and ZIP code PERMIT REQUEST INFORMATION Type of permit request Name of event Date of event month day year Annual Event Hours of event Intended occupant load APPLICATION CERTIFICATION I or we hereby certify under penalty of perjury that the information contained in this application is true and accurate to the best of my knowledge and belief and that the operation of the place of amusement or entertainment or events described above will conform in every respect and at all times with the laws rules and regulations of the Fire Prevention and Building Safety Commission and will not be used for other purposes except as herein stated* Signature Date month day year PERMIT FEES Fees are based on occupancy load effective September 30 2006. 1 - 99 persons 500 - 999 persons 10 000 persons or more 99. 00 134. 00 168. 00 203. 00 272. 00 Date permit issued month day year Date of reinspection month day year Date of inspection month day year Type of permit Fee amount / year of permit 20. .

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