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Revised: 3/26/09 1 PERMIT APPLICATION: OUTDOOR FIREWORKS DISPLAY 1. Name/Company: 2. Company Phone 3. Mailing address: 4. Physical address if different from above: 5. City/State/Zip: 6. F.I.D.(Federal Identification Number): 7. Name and driver’s license number of person making application (PRINT): 8. Sponsorship. 8.1. The fireworks display will be sponsored by: 8.1.1. Name and telephone number of the sponsor’s representative: ( ) - 8.2. The fireworks display will occur at (Provide location by listing address, street intersections, name of complex or facility, etc. Include name of City, County or Town): 9. The firing of display fireworks will occur on: (Date): / / 20 beginning at (time) am/pm and end at (time) am/pm. 9.1. [ ] Check this box if the firing of identical display firework setups will occur on multiple succeeding (sequential) dates and/or times. List all the dates and times on a separate page and attach it to this application. See application instructions for Lines 9.1 and 14.) 9.2. In case of postponement due to weather or for other reason(s), the alternate date and time for line # 9 is: (Date): / / 20 beginning at (time) am/pm and end at (time) am/pm. 9.3. The expected arrival of the operator (pyrotechnician) and product will be at (time) am/pm on (Date) / / 20 . 10. Operators, Assistants and Pyrotechnic Specifications. 10.1. Name and age of the pyrotechnic operator (person actually in charge of firing the display fireworks): All information must be printed in ink or typewritten. Submit two copies of this application and all its attachments to the County Fire Marshal not less than 15 days prior to the event for timely processing. Lic. Number: State of issuance: ---PAGE BREAK--- Revised: 3/26/09 2 10.2. List of any qualifications/credentials the operator may possess or is willing to offer: 10.3. The pyrotechnic experience of the operator can be evidenced by having fired (check one in each column): Number of shows fired: During a period covering: [ ] 1 – 5 shows [ ] 1 – 6 months [ ] 6 – 10 shows [ ] 7 – 12 months [ ] 11 – 20 shows [ ] 13 – 24 months [ ] Over 20 shows [ ] Over 24 months 10.3.1. With the latest firing having occurred at (print): Name of facility: Date of firing: Physical address of facility: Name of sponsor: Telephone number of sponsor: 10.4. Name and ages of all shooters who will be present (attach additional pages as needed): Name (print) Age 11. List the size (in inches) and number of shells to be fired. Provided additional indication for multi-break shells and/or salutes (reports). Attach additional pages as needed: # Size Type of shell 11.1. The display will be fired (check the appropriate box) [ ] Manual [ ] Electrically [ ] Combined 11.2. Answer the following question by placing a check mark in the appropriate box. Will mortars be reloaded during the display? [ ] Yes [ ] No 11.3. Mortars to be used will be constructed of (check all that apply): [ ] Steel [ ] Paper [ ] High Density Polyethylene [ ] Other (specify) ---PAGE BREAK--- Revised: 3/26/09 3 12. Additional Attachments. The following items are to be provided as attachments to this application. 12.1. [ ] A diagram of the grounds or facilities where the display will be held. (See application instructions.) The diagram is not required to be to scale but it is to show: 12.1.1. [ ] the fallout radius (with an indicated distance in feet) for the largest shell to be used in the display; and 12.1.2. [ ] the points at which the shells and/or cakes are to be positioned and fired; and 12.1.3. [ ] the lines behind which the audience will be restrained (with an indicated distance in feet); and 12.1.4. [ ] location of significant buildings (with an indicated distance in feet), highways, overhead obstructions and utilities; and 12.1.5. [ ] the indicated direction of North. 12.2. [ ] Proof of a corporate surety bond or a public liability insurance policy in an amount acceptable to the sponsor noted on Line 8.1 but not less than $500,000.00. 13. Conditions and acknowledgement. The applicant is required to review and initial the following requirements of the Statewide Fire Prevention Code (SFPC) and its referenced standards. By initialing each item, the applicant acknowledges their review and agreement to comply with any listed requirements as expressed in the SFPC. (If the item does not apply to the circumstance, the applicant is to write N/A in place of their initials.) 13.1. Each shell is marked to indicate its size “3-in. shell”), type “2-break with report”) and provides the name of the manufacturer, importer, or distributor. 13.1.1. The shell has a conspicuous warning label stating the shell is a dangerous explosive and is of a contrasting color to its background. 13.1.2. Each type of aerial salute is conspicuously marked with the word “Salute.” 13.2. If reloads are used during the display, the ready box will be capable of protecting the contents from burning debris with a self-closing cover or by an equivalent means or method. 13.2.1. During the performance of the display, the ready box will be located at least 25 feet upwind from the mortar placement. 13.2.2. The reloading of shells will be confined to shells with a 6-inch or less diameter. 13.3. The display site has a radius of not less than 70 feet per inch of diameter of the largest shell to be fired. The display site radius from health care and detention/correctional facilities, or to the bulk storage area of materials that have a flammability, explosive, or toxic hazard, will not be less than 140 feet per inch of diameter of the largest shell to be fired. 13.3.1. No spectators or spectator parking will be located within the display site. 13.3.2. Any ground display pieces used will be located a minimum distance of 75 feet from spectator viewing and parking areas. 13.3.3. After consulting with the sponsor, assurance is provided that the sponsor has made provisions to provide adequate fire protection for the display site and the local fire department has been made fully aware of the anticipated fireworks display. 13.3.4. The sponsor has made provisions to provide a sufficient number of monitors, with distinctive identification badges, colored vests, etc.), whose sole duty is enforcement of crowd control around the display area. The sponsor will determine the number of monitors with the concurrence of the SFMO and operator. Where practical, fences and rope barriers can be incorporated by the monitors to aid in crowd control and will not to be used to supplant the number of monitors. 13.4. When firing shells electrically, the firing system is designed to ensure against accidental firing by providing at least a two-step interlock process that requires the operator to intentionally enable or arm the firing system; and deliberately apply firing power. 13.4.1. The power source used for firing pyrotechnic devices is restricted to batteries or isolated power supplies used for firing purposes only. 13.4.2. Any shell larger than 6-inches in diameter will be pre-loaded into the mortar(s) and fired electrically. 13.5. Except for securely fastened mortar racks; mortars will be buried to a depth of at least 66.6% of their length. ---PAGE BREAK--- Revised: 3/26/09 4 13.5.1. When mortars are to be reloaded during a display, mortars of various sizes will not be intermixed. Mortars of the same size will be placed in groups according to size and groups will be separated from one another. 13.5.2. Mortars will be of sufficient length, strength and durability to fire the aerial shells safely and to safe heights. 13.5.2.1. The tensile strength of steel pipe mortars will be at least 40,000 psi. Metal mortars with seams will placed so that all seams face either left or right when viewing the line of mortars. The walls of steel mortars will be a minimum thickness of: Mortar ID (in.) Spherical Cylindrical Single Break Cylindrical Multi-Break 3 0.04 0.11 0.21 4 0.05 0.12 0.23 5 0.06 0.13 0.25 6 0.07 0.14 0.27 8 0.09 0.16 0.31 10 0.11 0.18 0.35 12 0.13 0.20 0.39 13.5.2.2. The cross-grain tensile strength of paper mortars will be at 2300 psi. The wall of paper mortars will be a minimum thickness of: Mortar ID (in.) Spherical Cylindrical Single Break Cylindrical Multi-Break 3 0.25 0.25 0.37 4 0.25 0.33 0.50 5 0.31 0.42 0.62 6 0.37 0.50 0.75 8 0.50 0.62 - 10 0.62 - - 12 0.75 - - 13.5.2.3. The tensile strength of High Density Polyethylene1 plastic mortars will be at least 3500 psi. The wall of plastic mortars will be a minimum thickness of: Mortar ID (in.) Spherical Cylindrical Single Break Cylindrical Multi-Break 3 0.15 0.20 3 4 0.20 0.26 3 5 0.25 3 3 6 0.30 3 3 8 2 3 3 10 2 3 3 12 2 3 3 1 If any other plastic pipe is used, such as PVC, please provide proof or evidence the material meets or exceeds the 3500 psi threshold. 2 Data not currently available 3 Provide documentation from plastic manufacturer that provides evidence or proof the material meets or exceeds the 3500 psi threshold. 13.5.2.4. The inside mortar length will be a minimum of: Mortar ID (in.) Single Break Double Break Up to 4-Break 3 15 18 21 4 20 23 27 5 24 28 32 6 28 32 37 8 34 40 46 10 40 46 54 12 46 52 62 ---PAGE BREAK--- Revised: 3/26/09 5 14. By my signature below, I attest the above information is accurate and correct. I acknowledge and agree to comply with all applicable requirements of the Virginia Statewide Fire Prevention Code (SFPC) and the referenced NFPA 1123- 00 standard governing the use, storage and firing of display fireworks, even those not specifically expressed on this application. I also acknowledge that if a permit is issued based upon this application, it shall: 1. Be valid only at the location listed on the application, and for the specific date(s) and time(s) for which it is issued; and 2. Does not convey approval to store explosives (display fireworks) beyond the temporary (less than 24- hour) on-site storage of the display fireworks on the date of the approved display. If approved for permit issuance, I acknowledge that a copy of this application and all its attachments will be available on-site during the dates and times noted for lines 9.1 and 9.2 of the application, and constitutes approval to proceed with the activity applied for. I further acknowledge and understand that any SFPC violations identified after permit issuance may result in immediate permit suspension or revocation. 15. Signature of applicant (person listed on line 16. Date: Permit To be completed by SFMO personnel only: Application reviewed by (print name): Review date: Application for permit is: [ ] Approved [ ] Not Approved Reviewer’s comments, additional conditions, or reasons for non-approval: Signature of reviewer: