CITY OF MUSKEGO APPLICATION FOR STORAGE AND USE OF

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CITY OF MUSKEGO APPLICATION FOR STORAGE AND USE OF Powered By Docstoc
					                                                 CITY OF MUSKEGO
                                 APPLICATION FOR STORAGE AND USE OF EXPLOSIVES
                                    Reference Municipal Code - Chapter 12.15

License Year July 1 - June 30                                   Amount Received __________________
$25.00 60-Day Permit                                            Date _____________________________
$50.00 Annual Permit                                            Receipt #_________________________
                                                                Acct. #100.01.02.00.4279 (2-220)


____________________________________________________________________________________
LAST NAME                           FIRST                     MIDDLE

____________________________________________________________________________________
STREET ADDRESS                               CITY             STATE     ZIP

____________________________________________________________________________________
HOME PHONE                        WORK PHONE                  OCCUPATION

ADDRESS AND LOCATION OF BUILDING WHERE MATERIAL IS TO BE USED OR STORED: ___________

____________________________________________________________________________________

ESTIMATED DURATION OF STORAGE (MONTH/YEAR):                _______________________________________

DESCRIPTION OF EXPLOSIVE MATERIAL OR DEVICE:               ______________________________________

____________________________________________________________________________________

PURPOSE OR USE INTENDED:                __________________________________________________________

OTHER INFORMATION AS REQUESTED BY THE CHIEF OF POLICE: _____________________________

____________________________________________________________________________________

INDEMNITY BOND (REQUIRED BY MAYOR) NOT TO EXCEED $300,000:
     NO _____     YES _____     AMOUNT: _________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *


___________________________________                      _________________________________________
Date                                                     Signature of Applicant


___________________________________                      _________________________________________
Date Approved                                            Chief of Police


                                                         _________________________________________
                                                         Mayor
c:     Aldermen
       Bldg Inspection Director
       Fire Departments

Cityhall/Masters:AP-Explosives