PENNSYLVANIA PERMIT APPLICATION             PERMIT FOR PURCHASE AND DISPLAY OF CONSUMER FIREWORKS                    AS PERMITTED BY 35 P.S. 1275.2                        This Permit authorizes the Applicant ___________________________________________________________, to purchase consumer fireworks from __________________________________________________________, for the display of consumer fireworks at _________________________________________________________ _______________________________________________________________________________________ ________________________________ ; ____________________________________________ County, PA. The date for this consumer fireworks (1.4g) display event is _________________________________________ which shall not be less than three days from the date of delivery of this Permit to the retailer of consumer fireworks.  The grant of this Permit is a non-transferrable privilege, which is valid only for the date identified as the consumer fireworks display event day.  The applicant agrees that he or she will fire or discharge the consumer fireworks as or with a competent operator, and that the consumer fireworks display will not be hazardous to property or endanger any person or persons.  The applicant releases the Municipality and retailer of the consumer fireworks from liability, losses and/or claims, which may arise from the display of consumer fireworks. BY:_________________________________________________  Date:______________________________         Signature of Municipal Officer       _________________________________________________            ______________________________         Printed Name of Municipal Officer                                                                Title of Municipal Officer       _________________________________________________             ______________________________         Daytime Telephone Number                                                                           Permit Number