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2. 
3. City of Middleton Fireworks Application
5. Per City of Middleton Code of Ordinances
   Chapter 5

   Section 5.15

7. Organization Name
8. Contact Person
10. Address1
12. City
13. State
14. Zip
16. Phone Number
17. E-mail address
19. Name of Event*
20. Date of Event*
    Date of Event
24. Organization Officers

    Complete for each officer of the organization (attach list if necessary)

26. First Name*
27. Last Name*
29. Phone Number*
30. E-mail address*
32. Address1*
34. City*
35. State*
36. Zip*
38. Upload Driver's License/State ID*
39. Upload additional information here
43. First Name
44. Last Name
46. Phone Number
47. E-mail address
49. Address1
51. City
52. State
53. Zip
55. Upload Driver's License/State ID
59. Person Responsible for Supervision permitted activity
61. First Name*
62. Last Name*
64. Phone Number*
65. E-mail address*
69. Is this permit for possession and storage only?*

    1. Yes

    1. No
71. If yes, please list the dates and locations of possession and storage
73. If no, please list the dates and locations of use
77. Attachments/Other Conditions

    The following items are also recommended: 

    1) use of low-noise, or no-noise fireworks. The use of low/no-noise considers veterans with PTSD, other people with sensitivity to loud noises, and pets that may panic and run away, thus needing the help of the police and humane society 

    2) use of low or no perchlorate‐containing fireworks

    3) due to the potential exposure to smoke and particulate matter produced during fireworks displays individuals with respiratory and/or cardiovascular diseases should be urged to take appropriate precautions when attending the event, or view from a safe distance to reduce exposure 

    4) all debris and unburned shell fragments be cleaned up entirely the following day

    5) any "misfires" or "duds" be located and disposed of properly

79. Upload the following documents:
81. Mortar configuration and specifications*
82. Indemnity Bond*
83. List of all fireworks to be used in display*
84. Resumes and State Driver's License/ID for each pyro technician*
86. Site Plan*

    Site Plan Showing:

    a. Firing location 

    b. Device layout 

    c. Location of spectators 

    d. Distance of spectators from firing location 

    e. Fallout perimeter 

    f. Storage area for fireworks 

    g. Distances to all structures from the firing location 

87. Public Notice*
88. Pre-inspection Date *
    Pre-inspection Date

    Pre-inspection Date

    Contact the Middleton FIre Department to schedule a pre-inspection date 608-827-1090

90. Payment Method*

    1. Online
    2. Mailing Check

    Once you hit submit, you will be directed to the credit card processing page.  You may also mail a check to our office at 7426 Hubbard Avenue, Middleton, WI  53562.

94. I attest that the above information is true and correct and that any false or incomplete information may result in denial of my application.
96. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
97. Initial here*
99. Please type name as shown on application above*
100. Date*
     Date
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field