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Modesto Fire Department FIRE PREVENTION DIVISION 409 12th Street, Modesto, California 95354 Tel: (209) 571-5553 Fax: (209) 544-1652 THEATRICAL OPEN-FLAME PERFORMANCE PERMIT APPLICATION (See 2016 CFC 308.3.2 and NFPA 160.) Name and Phone of Pyrotechnic Operator: (if applicable) Pyrotechnic Operator License No. and Expiration Date: Name and Phone of Applicant: Applicant’s Residence Address: Name of Performance Facility: Address of Facility: Owner of Facility and Phone No.: Date(s) and Time(s) of Performance(s): • Fully describe performance. (Use additional sheet ifneeded.) • List all flammable and combustible liquids / solids to be used and their quantity. (Use additional sheet if needed.) 1. 2. 3. 4. 5. 6. • Describe safety precautions to be implemented. (Use additional sheet ifneeded.) • Attach a site diagram showing audience area, performance area, exit doors, aisles, distances, etc. Applicant’s Signature: Date: In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at revised 06/23/20 SIGN