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Blank Indiana Entertainment Permit PDF Template

The Indiana Entertainment Permit form is a document required for venues hosting various entertainment events in the state of Indiana. This form must be completed and submitted to the Department of Homeland Security's Division of Fire Safety to ensure compliance with safety regulations. Proper submission includes providing an updated floor plan and, if applicable, a valid 501c letter to claim exempt status.

Open Indiana Entertainment Permit Here

Open Indiana Entertainment Permit Here

Outline

The Indiana Entertainment Permit form is a crucial document for anyone looking to host events or operate entertainment venues within the state. This form, officially known as the Application for Amusement, must be completed and submitted to the Department of Homeland Security’s Division of Fire Safety. It serves multiple purposes, primarily ensuring that facilities meet safety standards and regulations. When filling out the form, applicants need to provide detailed information about the venue, including its type—be it a theater, dance hall, or special event space—as well as the specific address and facility description. Additionally, the form requires applicants to indicate their status, whether they are the owner, operator, or lessee of the venue. An updated floor plan must accompany the application, and if the applicant claims exempt status, a valid 501c letter should also be included. The permit request section allows applicants to specify the type of event, its date, and expected occupancy load, which influences the fee structure based on the number of attendees. Completing this form accurately is essential, as it includes a certification statement that affirms the truthfulness of the information provided and compliance with applicable laws. Understanding the requirements and processes associated with the Indiana Entertainment Permit form can help ensure a smooth application experience and successful event planning.

Form Sample

	APPLICATION FOR AMUSEMENT	Return this completed form to:
	ENTERTAINMENT PERMIT	Return this completed form to:
	ENTERTAINMENT PERMIT
	State Form 42235 (R6 / 2-10)	DEPARTMENT OF HOMELAND SECURITY
	State Form 42235 (R6 / 2-10)	DIVISION OF FIRE SAFETY - PERMIT DIVISION
	Approved by State Board of Accounts, 2010	DIVISION OF FIRE SAFETY - PERMIT DIVISION
	Approved by State Board of Accounts, 2010	302 West Washington Street, Room E241
		302 West Washington Street, Room E241
		Indianapolis, Indiana 46204

INSTRUCTIONS: 1. Include an updated floor plan with this application.

2. If claiming exempt status, include a valid 501c letter with this application.

FOR OFFICE USE ONLY

Permit number

Receipt number

FACILITY INFORMATION

Type of facility	Theater	Dance Hall		Night Club	Cabaret	Special Event		Other (specify)
	Theater	Dance Hall		Night Club	Cabaret	Special Event		Other (specify)
	Assembly Hall	Roller Rink		Lodge Hall	Carnival Fair	Gymnasium		__________________

Name of facility					City		County

Address of facility (number and street, city, state, and ZIP code)

Specific room or floor number			Description of facility

Closest intersecting street or road					Direction from intersection
					North		South	East	West

APPLICANT INFORMATION

Type of applicant
Owner	Operator	Lessee

Name of applicant

Telephone number

()

Address of applicant (number and street, city, state, and ZIP code)

If incorporated, name of principal officer of corporation

Name of person to contact for inspection	E-mail address

Address of contact person (number and street, city, state, and ZIP code)		Telephone number
		(	)

Responding fire department

Address of fire department (number and street, city, state, and ZIP code)

PERMIT REQUEST INFORMATION

Type of permit request
Special Event Endorsement	Annual Event

Name of event

Date of event (month, day, year)	Hours of event	Intended occupant load

If Special Event Endorsement, existing operating permit number

APPLICATION CERTIFICATION

I, or we, ________________________________________________, hereby certify, under penalty of perjury, that the information contained in this

application is true and accurate to the best of my knowledge and belief and that the operation of the place of amusement or entertainment or events described above will conform in every respect and at all times with the laws, rules, and regulations of the Fire Prevention and Building Safety Commission and will not be used for other purposes except as herein stated.

Signature

Date (month, day, year)

	PERMIT FEES
Fees are based on occupancy load, effective September 30, 2006.
1 - 99 persons	$99.00
100 - 499 persons	$134.00
500 - 999 persons	$168.00
1,000 - 4,999 persons	$203.00
5,000 - 9,999 persons	$237.00
10,000 persons or more	$272.00
Special Event Endorsement	$99.00

FOR OFFICE USE ONLY

Date permit issued (month, day, year) Date of reinspection (month, day, year) Date of inspection (month, day, year) Type of permit

Fee amount / year of permit

20 _____

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Form Specifics

Fact Name	Details
Governing Law	The Indiana Entertainment Permit is governed by the Fire Prevention and Building Safety Commission laws.
Application Purpose	This form is used to apply for an entertainment permit for various types of facilities, such as theaters, dance halls, and special events.
Submission Location	Completed applications must be sent to the Department of Homeland Security, Division of Fire Safety - Permit Division in Indianapolis.
Required Attachments	An updated floor plan must accompany the application. If claiming exempt status, a valid 501c letter is also required.
Permit Types	Applicants can request a Special Event Endorsement or an Annual Event permit, depending on their needs.
Occupancy Fees	Permit fees vary based on the intended occupant load, ranging from $99 for 1-99 persons to $272 for 10,000 persons or more.
Certification Requirement	Applicants must certify that the information provided is accurate and that the facility will comply with all relevant laws and regulations.
Contact Information	Applicants must provide contact details for the person responsible for inspections and the responding fire department.

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