Form SF044 "Application for Class B Fireworks (Fireworks 1.3g) Singular or Multiple Display Permit" - Texas

What Is Form SF044?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form SF044 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form SF044 "Application for Class B Fireworks (Fireworks 1.3g) Singular or Multiple Display Permit" - Texas

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Rate (4.3 / 5) 27 votes
   
 
   
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
   
 
 
 
   
 
   
 
 
 
 
 
 
 
  
 
 
   
     
 
 
   
 
 
 
 
 
 
 
   
   
 
 
   
   
   
  
 
 
   
 
 
   
 
 
 
   
     
    
 
 
 
 
 
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
   
   
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
     
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
SF044 | 0215
APPLICATION FOR CLASS B FIREWORKS (FIREWORKS 1.3G)
SINGULAR OR MULTIPLE DISPLAY PERMIT
This application must be accompanied by the appropriate fee and all documents and information required by Chapter 2154 of the
Texas Occupations Code and the Fireworks Rules. Complete answers must be given to all questions.
Please print or type.
A public fireworks display permit may not be issued to any person who is under 21 years of age. Any fraudulent representation on
this application shall be cause for denial, suspension, or revocation of a permit. All fees are non‐refundable, except for
overpayments resulting from mistakes of law or fact.
PERMIT
CHECK ONE
TYPE OF PERMIT
PERMIT FEE
CODE
Singular Display Permit
$50.00
570‐07
Multiple Display Permit
$400.00
570‐08
APPLICANT
NAME OF APPLICANT
Telephone No. ___________________
Fax No. ________________________
ADDRESS
CITY
STATE
ZIP
(optional)
(optional)
E
MAIL ADDRESS FOR NOTIFICATION PURPOSES
WEB SITE ADDRESS
Applicant doing business as (Check One)
Yes
No
Individual.
Corporation
Is the individual 21 years of age or older?
Yes
No
Partnership.
Other – describe:
Is each partner 21 years of age or older?
Federal employer's identification (FEI) number:
DISPLAY INFORMATION
Date of display
______________________________________
Time
____________________________
Alternate date of display
______________________________________
Time
____________________________
Exact location description or address of display and/or alternate location for the display
Pyrotechnic operator licensed in Texas who will be at the display site to supervise the display:
Name
License number
Name
License number
Name
License number
Texas Department of Insurance | www.tdi.texas.gov
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SF044 | 0215
APPLICATION FOR CLASS B FIREWORKS (FIREWORKS 1.3G)
SINGULAR OR MULTIPLE DISPLAY PERMIT
This application must be accompanied by the appropriate fee and all documents and information required by Chapter 2154 of the
Texas Occupations Code and the Fireworks Rules. Complete answers must be given to all questions.
Please print or type.
A public fireworks display permit may not be issued to any person who is under 21 years of age. Any fraudulent representation on
this application shall be cause for denial, suspension, or revocation of a permit. All fees are non‐refundable, except for
overpayments resulting from mistakes of law or fact.
PERMIT
CHECK ONE
TYPE OF PERMIT
PERMIT FEE
CODE
Singular Display Permit
$50.00
570‐07
Multiple Display Permit
$400.00
570‐08
APPLICANT
NAME OF APPLICANT
Telephone No. ___________________
Fax No. ________________________
ADDRESS
CITY
STATE
ZIP
(optional)
(optional)
E
MAIL ADDRESS FOR NOTIFICATION PURPOSES
WEB SITE ADDRESS
Applicant doing business as (Check One)
Yes
No
Individual.
Corporation
Is the individual 21 years of age or older?
Yes
No
Partnership.
Other – describe:
Is each partner 21 years of age or older?
Federal employer's identification (FEI) number:
DISPLAY INFORMATION
Date of display
______________________________________
Time
____________________________
Alternate date of display
______________________________________
Time
____________________________
Exact location description or address of display and/or alternate location for the display
Pyrotechnic operator licensed in Texas who will be at the display site to supervise the display:
Name
License number
Name
License number
Name
License number
Texas Department of Insurance | www.tdi.texas.gov
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SF044 | 0215
QUESTIONS
Size and estimated number of 1.3G fireworks to be discharged:
Other items (1.4G fireworks, flame effects, set pieces, etc.)
Manner and address of storage of fireworks prior to and during the display
Manufacturer or distributor licensed in Texas who is to supply the fireworks:
Name
License number
SIGNATURES
In applying for a fireworks permit, I certify that I am familiar with and will comply with Chapter 2154 of the Texas Occupations Code and the
Fireworks Rules.
I hereby authorize the state fire marshal or any of his duly authorized deputies, upon notice, to enter, examine, and inspect any premises, building,
room, or establishment used in connection with the permit for which I am applying to determine compliance with the provisions of Chapter 2154
and the Fireworks Rules.
By my signature, I verify that the information on this application and its attachments are true.
I understand that knowingly providing a false answer to any question or submitting false information or documents with this application may be
tampering with a governmental record which is punishable under the Texas Penal Code Chapter 37, §37.10.
Printed name
Title
Signature
Date
Printed name
Title
Signature
Date
APPLICATIONS MUST BE SIGNED BY AN INDIVIDUAL APPLICANT, BY AN OFFICER OF A CORPORATION, BY THE SOLE PROPRIETOR, BY EACH
PARTNER OF A GENERAL PARTNERSHIP, BY THE GENERAL PARTNER OF A LIMITED LIABILITY PARTNERSHIP OR BY AN OFFICER OR MEMBER OF A
LIMITED LIABILITY COMPANY.
APPLICATIONS SUBMITTED BY A GOVERNMENTAL ENTITY MUST BE SIGNED BY THE APPROPRIATE OFFICER.
FOR EXAMPLE, A CITY’S
APPLICATION SHOULD BE SIGNED BY THE MAYOR, CITY MANAGER, CITY ADMINISTRATOR, CITY SECRETARY, ETC.
Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE.
Mail this completed application along with the appropriate fee and additional documents to:
Mail Address:
State Fire Marshal’s Office
Physical Address:
State Fire Marshal’s Office
Mail Code 9999
333 Guadalupe
P. O. Box 149221
Austin, TX 78701
Austin, TX 78714‐9221
Fax No.
(512) 490‐1056
(512) 676‐6808
Web Site Address:
www.tdi.texas.gov/fire
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under
sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including
private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the
Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information
about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the
Agency Counsel Section of TDI’s General Counsel Division at (512) 676‐6551 or visit the Corrections Procedure section of TDI’s website at
www.tdi.texas.gov
.
Texas Department of Insurance | www.tdi.texas.gov
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SF044 | 0215
SINGULAR OR MULTIPLE DISPLAY PERMIT SITE DIAGRAM/PLAN
Please make sure the below listed items are included on the site diagram
Address of display location
Show location of firing site
Show location of spectators
Show minimum secured area on all sides of firing site
Show method of restraint/security on all sides of firing site
Show location of health care, detention and correctional facilities. If there are no such facilities
within the distance required by NFPA 1123, 1995 ed., please indicate such in a statement on the
diagram.
Show location of school buildings and/or churches. If there are no buildings within 600 feet of the
firing site, please indicate such in a statement on the diagram.
Show location of hazardous materials. If there are no hazardous materials within the distance
required by NFPA 1123, 1995 ed., please indicate such in a statement on the diagram.
Texas Department of Insurance | www.tdi.texas.gov
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SF044 | 0215
Texas Department of Insurance
State Fire Marshal’s Office
Application for Class B Fireworks (Fireworks 1.3G) Singular or Multiple Display Permit
Site Inspection Certification
1. Name of applicant __________________________________________________________________________________________________
Address ________________________________________________________
Telephone ____________________________________
City ________________________________________________________
State ______________
Zip Code __________________
2. Date of display ___________________________________________________________
Time _________________________________
Alternate date of display ___________________________________________________
Time _________________________________
3. Location and/or alternate location for the display _________________________________________________________________________
__________________________________________________________________________________________________________________  
__________________________________________________________________________________________________________________  
__________________________________________________________________________________________________________________  
 Yes
 No
4. As the fire prevention officer, I approve of the display site and have reviewed the site diagram.
 Yes
 No
5. I approve of the location and manner for storage of display fireworks before and during the display.
 Yes
 No
6. I approve of the potential landing area for fireworks debris.
7. The display is to be conducted in compliance with TX Occupations Code,
 Yes
 No
Regulation of Fireworks & Fireworks Displays and the Fireworks Rules.
8. My approval is subject to the following conditions.
List conditions, if applicable, or indicate “None” __________________________________________________________________________
__________________________________________________________________________________________________________________  
__________________________________________________________________________________________________________________  
9. As the appropriate fire prevention officer, I have inspected the display site(s) to determine whether this proposed display is of a nature or in a
location that may be hazardous to property or dangerous to any person. This form is my notice to the state fire marshal of the results of the
inspection as required in Sec. 2154.206, Chapter 2154, Texas Occupations Code.
Signature of fire prevention officer ______________________________________________
Date _____________________________
Printed name of fire prevention officer ___________________________________________
Title _____________________________
Department _________________________________________________________
Telephone No. _____________________________
Email address: ________________________________________________________
Mobile Phone No. __________________________
Telephone No.
(512) 676‐6808
Fax No.
(512) 490‐1056
Web Site Address
www.tdi.texas.gov/fire
Texas Department of Insurance | www.tdi.texas.gov
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SF044 | 0215
APPLICATION FOR CLASS B FIREWORKS (FIREWORKS 1.3G)
SINGULAR OR MULTIPLE DISPLAY PERMIT
APPLICANTS FOR A SINGULAR OR MULTIPLE DISPLAY PERMIT MUST SUBMIT THE FOLLOWING:
1.
An application for a singular or multiple display permit.
2.
A certificate of general liability insurance.
ITEMS TO BE INCLUDED ON INSURANCE CERTIFICATES:
1.
The name of the insurer and the policy number.
2.
The name of the insured, which must be the same name as on the display application.
3.
Effective dates (or days) of the policy.
4.
The amount of coverage must not be less than $500,000. The policy shall be conditioned to pay those sums the insured becomes
obligated to pay as damages because of bodily injury and property damage caused by an occurrence involving the insured or the
insured’s servant, officer, agent, or employee in the conduct of a public fireworks display.
5.
The words “fireworks display” and the dates(s) of the display should appear under description of operations on the certificate. Any
alternate date(s) should also be included.
6.
The State Fire Marshal’s Office should be listed as the certificate holder.
7.
Must be issued by an insurer authorized to do business in Texas and countersigned by an insurance agent licensed in Texas.
ADDITIONAL DOCUMENTS
If you are a
If you are a
If you are a
If you are a
Texas or Foreign Corporation
Sole Proprietorship or
Texas or Foreign
Texas or Foreign
submit the following
General Partnership
Limited Partnership
Limited Liability Company
submit the following:
submit the following
submit the following
Certificate of general liability
Certificate of general liability
Certificate of general liability
Certificate of general liability
insurance
insurance
insurance
insurance
Corporate Charter, Certificate
Certificate of Limited
Certificate of Organization, or
of Existence, or Certificate of
Partnership, Registration
Certificate of Authority issued
Authority issued by the Texas
Application for Foreign
by the Texas Secretary of
Secretary of State
Limited Partnership
State
Franchise Tax Account Status
Franchise Tax Account Status
Franchise Tax Account Status
must be ACTIVE with the TX
must be ACTIVE with the TX
must be ACTIVE with the TX
Comptroller of Public
Comptroller of Public
Comptroller of Public
Accounts
Accounts
Accounts
Assumed Name Certificate
Assumed Name Certificate
Assumed Name Certificate
Assumed Name Certificate
from Texas Secretary of State
from your County Clerk
from Texas Secretary of State
from Texas Secretary of State
(if using a d/b/a)
(if using a d/b/a)
(if using a d/b/a)
(if using a d/b/a)
Texas Secretary of State: (512) 463‐5578
Texas Comptroller of Public Accounts (800) 252‐1386
Texas Department of Insurance | www.tdi.texas.gov
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