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Revised: 3/26/2009 1 Cumberland County, Virginia FIREWORKS PERMIT APPLICATION INSTRUCTIONS: Application for the USE OF PYROTECHNICS INSIDE buildings and OUTDOORS Before a Proximate Audience Line 1. Provide name of person or company applying for a permit. Line 2. List telephone number where applicant may be reached. Line 3. Use mailing address the applicant can expect the quickest service. Line 4. What is the physical address (location) of the permit applicant if it’s different from the mailing address given? Line 5. List city, state and zip code for the complete mailing address. Line 6. If a company is making application, write in the Federal Identification Number as provided by the IRS for the company applying for the permit. If a company is not making application, disregard and go to Question Line 7. Print the name of the person submitting the application with their driver’s license number and the state of licensure issuance. Line 8. The use of pyrotechnics before a “proximate audience” is governed by provisions contained in the Virginia Statewide Fire Prevention Code (SFPC) and its incorporated NFPA 1126-01 standard. This application is for a permit to use NFPA 1126 – type devices, sometimes referred to as “close proximity fireworks”, in circumstances listed on lines 8.1 through 8.5. (If the applicant desires to use pyrotechnics or materials in circumstances not listed, the applicant should immediately consult with the State Fire Marshal’s Office for further guidance, direction or information.) Line 9. The SFPC requires a “plan for the use of pyrotechnics”. Line 9.1. The plan is to include the name of the sponsoring group, person or organization. Line 9.2. The exact location of the production or firing is to be listed. Include as much information as may be available such as street address, City, County or Town, facility name, building name or number if assigned one, etc. Line 9.2.1. Provide the name of the venue manager who has overall responsibility for the operation and management of the facility or site where pyrotechnics are to be used. Line 10. Provide the date and time-frame the use of pyrotechnics will occur. Line 10.1. The box is to be checked if the use of pyrotechnic devices will occur on multiple, sequential days (dates). Checking this box is intended to apply only to those multi-day displays that are identical in location, types and numbers of devices. If the firing dates are not sequential, if the number and/or types of devices are not identical to the day before, or if identical device setups will occur at different locations or dates, a new permit is required. If multiple dates are planned for identical setups, list the additional dates and times on a separate sheet. Label or indicate at the top of the sheet that it’s an attachment for line #10.1. Line 11 The SFPC provides an opportunity for the operator to prove to the fire official, sponsor and venue manager that the pyrotechnic devices will operate as planned and within the safety parameters required by the SFPC. Designate a date and time at which a walk-through can begin and a representative demonstration will be available. Line 12. The “plan” mentioned in line 9 requires specific informational items. Line 12.1. Provide the name and age of the operator that’s in charge of the design, setup and functioning of the pyrotechnics. The operator must be at least 21 years of age. Lines 12.2 and 12.3. List any qualifications or credentials the operator is willing to offer towards proof of being a qualified operator along with an accounting of actual experience in the number of shows within a 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. ---PAGE BREAK--- Revised: 3/26/2009 2 given period of time on line 12.3. If additional space is needed for line 12.2, attach an additional sheet (not to exceed the standard 8½ by 11 inch dimension) to the application and label or indicate at the top of the attached sheet that it’s an additional sheet for line # 12.2. Line 12.3.1. List the requested information as a reference. Line 12.4. List the names and ages of all assistants that will be present. All assistants must be at least 18 years of age. If additional space is needed for line 12.4, attach an additional sheet (not to exceed the standard 8½ by 11 inch dimension) to the application and label or indicate at the top of the attached sheet that it’s an additional sheet for line # 12.4. Line 12.5. The plan requires a listing of “the number and types of pyrotechnic devices and materials to be used.” If additional space is needed for line 12.5, attach an additional sheet (not to exceed the standard 8½ by 11 inch dimension) to the application and label or indicate at the top of the attached sheet that it’s an additional sheet for line # 12.5. Line 13. The “plan” mentioned in line 9 requires specific documents be provided. Placing a check in the boxes provided is a means for the applicant to determine or track for themselves they have obtained or possess the required information, and have attached it to the application. Line 13.1. A site plan is to be provided of the premises upon which the pyrotechnics will be fired. If the firing will be inside a building, a floor plan or diagram of the space is to be provided. In either case, the position at which the devices will be positioned for firing is to be noted, the fallout radius is to be indicated, and the lines behind which an audience will be restrained. Line 13.2. It’s to be noted on the site plan, floor plan or diagram where the assembly of devices will occur. Line 13.3. A material safety data sheet (MSDS) is to be provided for each type of device used. Lines 13.3.1 thru 13.3.3 requires that the name and address of the manufacturer of the devices be provided, along with any cautionary statements, and a statement noting the devices are intended for indoor use. Check the box provided if the devices are not being used inside a building. Line 13.4. A statement or certification is to be provided stating that sets, scenery, and rigging materials are inherently flame-retardant or have been treated to achieve a similar flame resistance. If such items will not be exposed or involved, check the box provided. Line 13.5. Proof of insurance or surety bond is required in an amount that is agreeable to the sponsor listed on Line 9.1 and the permit applicant, but shall not be less than $500,000.00. The proof of insurance or bond is to be attached to the application and submitted. Line 14. The SFPC has certain prerequisites, conditions and safeguards to be complied with by the operator of the pyrotechnic devices. This application is intended to have the applicant acknowledge these prerequisites, conditions and safeguards by reading and initialing each item (Lines 14.1 thru 14.7). If the listed item is not applicable to the circumstance, the applicant is to write “N/A” in place of their initials. An example of this is when close proximity fireworks are used outdoors and smoke detectors and air-handling systems would not be involved or affected. It would therefore be appropriate for the applicant to write “N/A” for lines 14.1 and 14.1.1 in place of their initials. Lines 15 through 17. Self-explanatory. An incomplete application is subject to being returned to the applicant without further processing. ---PAGE BREAK--- Revised: 3/26/2009 3 Cumberland County, Virginia FIREWORKS PERMIT APPLICATION: Application for the USE of PYROTECHNICS INSIDE Buildings and OUTDOORS Before a Proximate Audience 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. Of the following, check all circumstances for which application is being made: 8.1. [ ] For the use of pyrotechnics in theatrical, musical or similar productions before a proximate audience, performers, or support personnel. 8.2. [ ] The use of pyrotechnics while videotaping, audio taping, or filming of any television, radio, or movie production where such production takes place before a proximate audience. 8.3. [ ] The rehearsal of any production in which pyrotechnics are used. 8.4. [ ] The indoor use of pyrotechnics. 8.5. [ ] The outdoor use of pyrotechnics at distances less than those required by NFPA 1123, Code for Fireworks Display, as referenced by Section 3308.2.2 of the Virginia Statewide Fire Prevention Code. Note: Any permit issued as a result of this application does not confer approval to use flammable liquids and/or flammable gases in any performance or display. Separate approval must be provided for the use of such materials. 9. Sponsorship. 9.1. The use of pyrotechnic materials and/or devices will be sponsored by: 9.2. The use of pyrotechnics will occur at (Provide location by listing address, name of complex or facility, name or building number, etc. Include name of City, County or Town): 9.2.1. Name of venue manager: 10. The use of pyrotechnic materials and/or devices will occur on: (Date): / / 20 beginning at (time) am/pm and end at (time) am/pm. 10.1. [ ] Check this box if the firing of identical pyrotechnic materials or device 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. (Important - See application instructions for Line 10.1.) 11. A walk-through and representative demonstration of the pyrotechnics may be conducted. The walk-through and demonstration will be available to commence on (date) / / 20___ at (time) : am/pm prior to the Lic. Number: State of issuance: ---PAGE BREAK--- Revised: 3/26/2009 4 first rehearsal, production and/or performance at which pyrotechnics will be used, and will be completed with sufficient time allowed after the demonstration to reset/reload the pyrotechnics before the arrival of any audience. 12. Operators, Assistants and Pyrotechnic Specifications. 12.1. Name and age of the pyrotechnic operator (person actually in charge of firing the pyrotechnics): 12.2. List of any qualifications/credentials the operator may possess or is willing to offer: 12.3. 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 12.3.1. With the latest firing having occurred at (print): Name of facility: Date of firing: Physical address of facility: Name of venue manager: Telephone number of venue manager: 12.4. Name and ages of all assistants who will be present (attach additional pages as needed): Name (print) Age 12.5. List the number and types of pyrotechnic devices or materials to be used (attach additional pages as needed): # Name of device or material 13. Additional Attachments. The following items are to be provided as attachments to this application. ---PAGE BREAK--- Revised: 3/26/2009 5 13.1. [ ] A diagram of the grounds or facilities where the production is to be held. (See application instructions.) The diagram is to show: 13.1.1. [ ] the point at which the pyrotechnic devices are to be positioned and fired, 13.1.2. [ ] the fallout radius for each pyrotechnic device used in the performance, and 13.1.3. [ ] the lines behind which the audience will be restrained. 13.2. [ ] The point of on-site assembly of pyrotechnic devices. 13.3. [ ] A material safety data sheet (MSDS) for the pyrotechnic material(s) to be used and, 13.3.1. [ ] the name, address and phone number of the manufacturer, and 13.3.2. [ ] the manufacturer’s statement regarding whether the pyrotechnic is intended for indoor use, and [ ] Check this box if this item is not applicable to the circumstance. 13.3.3. [ ] whether it is to be used with any special considerations or cautions. 13.4. [ ] Certification that the set, scenery, and rigging materials are inherently flame-retardant or have been treated to achieve flame retardancy. [ ] Check this box if this item is not applicable to the circumstance. 13.5. [ ] Proof of a corporate surety bond or a public liability insurance policy in an amount acceptable to the sponsor noted on Line 9.1 and/or venue manage listed on Line 9.2.1 but not less than $500,000.00. 14. Conditions and acknowledgement. The applicant is required to review and initial the following requirements of the Statewide Fire Prevention Code and its referenced standards. By initialing each item, the applicant acknowledges their review and agreement to comply with the listed requirements. (If the item does not apply to the circumstance, the applicant is to write N/A in place of their initials.) 14.1. When the use of indoor pyrotechnics requires air-handling systems to be disengaged, the applicant will make timely and proper notification to a representative of the building owner who will be given the opportunity to be present for the firing of the pyrotechnic devices. The restoration of the building life safety systems shall be returned to normal operating conditions as soon as the likelihood of false alarms from the pyrotechnics has passed. 14.1.1. When the performance necessitates the bypassing of any smoke detectors, the applicant shall arrange for a fire watch officer, acceptable to the County Fire Marshal’s Office, to be available during performances and rehearsals. The fire watch officer shall be in direct communication with the local fire department. All smoke detectors shall be reactivated as the likelihood of false alarms has passed. 14.2. Binary materials shall be pre-weighed, pre-measured, pre-packaged, and identified by the manufacturer as being intended for indoor use. 14.3. Two or more fire extinguishers of the proper size and classification shall be readily accessible while the pyrotechnics are being loaded, prepared for firing, or fired. In all cases, at least two pressurized water extinguishers shall be available. 14.4. The pyrotechnic operator shall only use an electrical firing system. The firing system shall be 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. 14.5. The power source used for firing pyrotechnic devices is restricted to batteries or isolated power supplies used for firing purposes only. 14.6. All pyrotechnic device holders shall be constructed and secured so that they remain in a fixed position when the device is fired, and; 14.6.1. Comets and mines shall be fired so that the trajectory of the pyrotechnic material is not carried over the audience. 14.6.2. Waterfalls shall be placed for firing so that no flammable materials are within their fallout area. 14.6.3. Airbursts shall be fired above the assembled audience only if the airburst is suspended by a minimum 30-gauge metal wire firmly attached to a secure support; the airburst occurs at a minimum height of three times the diameter of the effect; there ---PAGE BREAK--- Revised: 3/26/2009 6 shall be no burning or glowing particles below the 15-foot level above the floor and proven during a demonstration. 14.6.4. Each pyrotechnic device fired during a performance shall be separated from the audience by at least 15 feet but not less than twice the fallout radius of the device, and project no glowing or flaming particles within 10 feet of the audience, that no part, projectile, or debris from the pyrotechnic material or device is propelled so that it damages overhead properties, overhead equipment, or the ceiling and walls of the performance area, and where pyrotechnics are fired, the quantity of smoke developed shall not obscure the visibility of exit signs or paths of egress; all of which may be proven during a demonstration. 14.6.5. Concussion mortars, if used, shall be separated from the audience by a minimum of 25 feet and placed in a secured location that prevents the audience and support personnel from gaining access to the secured location. 14.7. Pyrotechnic devices shall be fired only when the area where the effect is to occur is in clear view of the operator. 15. 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 Cumberland County Code and its referenced standard governing the use, storage and firing of pyrotechnics before a proximate audience, even those not specifically expressed on this application. I also acknowledge that if a permit is issued based upon this application, it shall only be valid within the building, facility and/or location listed on the application, and for the specific date(s) and time(s) for which it is issued. 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 10 and 10.1 of the application, and constitutes approval to proceed with the activities applied for. I further acknowledge and understand that any SFPC violations identified after permit issuance may result in immediate permit suspension or revocation. 16. Signature of applicant (person listed on line 17. Date: Permit To be completed by County Fire Marshal 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: