APPLICATION FOR AMUSEMENT ENTERTAINMENT PERMIT
State Form 42235 (R5 / 1-08) Approved by State Board of Accounts, 2008
Return this completed form to: DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE SAFETY - PERMIT DIVISION 302 West Washington Street, Room E241 Indianapolis, Indiana 46204
FOR OFFICE USE ONLY
Permit number Receipt number
Reset Form
Type of facility Name of facility Address of facility (number and street, city, state, and ZIP code) Specific room or floor number Closest intersecting street or road Description of facility
FACILITY INFORMATION Theater Assembly Hall Dance Hall Roller Rink Night Club Lodge Hall
City
Cabaret Carnival Fair
Special Event Gymnasium
County
Other (specify) __________________
Direction from intersection
North APPLICANT INFORMATION
Type of applicant Name of applicant
South
East
West
Telephone number
Owner
Operator
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 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) Telephone number
(
)
PERMIT REQUEST INFORMATION
Type of permit request Name of event
Special Event Endorsement
Date of event (month, day, year)
Annual Event
Hours of event Intended occupant load
If Special Event Endorsement, existing operating permit number
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 100 - 499 persons 500 - 999 persons 1,000 - 4,999 persons 5,000 - 9,999 persons 10,000 persons or more Special Event Endorsement FOR OFFICE USE ONLY
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
$99.00 $134.00 $168.00 $203.00 $237.00 $272.00 $99.00
$
20 _____