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2. Fees
   • Permit Fee: $10
   • Deposit: $200

   Submit cash or check for permit fee and deposit, made payable to City of Waukee to City Clerk, Waukee City Hall, 230 W. Hickman Road, Waukee, IA 50263.
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip
13. Email
14. Home Phone
16. Business Phone
17. Cell Phone
19. Applicant represents one of the following:

    1. Community association or organization
    2. Amusement park or fair association

    1. Waukee city agency / agencies
21. Date(s) of Display
    Date(s) of Display
22. Start Time
    Start Time
23. End Time
    End Time
25. Location of Display
27. Licensed and Competent Operator Responsible for Display (as defined by Code of Iowa Section 727.2)
29. Business Phone
30. Cell Phone
32. Type and Size of Fireworks in Display
    Describe in as much detail as possible.
34. Provide evidence of insurance covering permit holder and agents for display in the amounts as specified in Waukee Municipal Code 41.15(3)B.
36. Signature*

    I hereby agree to release and hold harmless and indemnify the City of Waukee, Iowa, the mayor and City Council of Waukee, and all those associated with the granting of the permit requested here in, from any and all damages and/or injuries, which may occur as a result of the use of the fireworks exploded under this permit; either to the operator or to other individuals as property as well as their heirs, assigns, executors, administrator and beneficiaries.

    1. I Agree
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field