Fireworks Permit Application - Wake County Government

FROM: Wake County Fire ServicesAttached you will find an application for a Fireworks Discharge Permit. PLEASE ALLOWFIVE (5) WORKING DAYS FOR PROCESSING. If you have any questions, please feel freeto contact us.ITEMS REQUIRED PRIOR TO PERMIT ISSUANCE:1. All blanks must be completed on the application.2. The Permit Holder is required to obtain liability insurance in an amount sufficient tocover the claims of any person(s) who may be injured or otherwise damaged as aresult of the display. The insurance must name Wake County as an additionalinsured and a copy of the Certificate of Insurance evidencing the coverage mustaccompany the application.3. Include a detailed site plan indicating the discharge and storage locations and distances.4. Include the manufacturer’s technical data sheet of each type of pyrotechnics to bedischarged.SECTION EXPLANATION:Section I:Section II:Section III:Section IV:Section V:Section VI:Section VII:Section VIII:Information on the person, group, corporation, association, or entitysponsoring, holding, or primarily responsible for the event.Information on the Display Operator and assistants.Information on the actual display.Public Safety Information. (Name of fire district where the discharge willtake place, address of the nearest fire station, and name and location ofthe nearest medical facility.)Notarization of the application. (APPLICATION SIGNATURES MUSTBE NOTARIZED.)Fire Department Comments. (This must be completed by the Chief ofthe local fire department representing the district where the dischargewill take place.)For Wake County Fire Services use only.Fireworks Permit Number.THE FIREWORKS PERMIT MUST BE ON SITE DURING THE DISCHARGE OF THEPYROTECHNICS.9512WFP1

Wake CountyApplication for Fireworks Discharge PermitSection IIMPORTANT: THIS APPLICATION MUST BE RETURNED NO LATER THAN FIVE (5)WORKING DAYS PRIOR TO EVENT TO ENSURE PERMIT PROCESSING.PLEASE TYPE OR PRINTAPPLICANT INFORMATION: (Note: The applicant is the person, group, corporation,association, or other entity sponsoring, holding or primarily responsible for the event orenterprise for which this permit is requested.)Name: ______________________________ Telephone: ____________ homeAddress: ______________________________ ____________ work____________________________________________________________For a corporate applicant, indicate the name and address of the registered agent for service ofprocess:Name:Address:__________________________________________________________________________________________________________________________________President orCEO:__________________________________________________Indicate whether the applicant is or will be insured with respect to the discharge offireworks/pyrotechnics: YES __________ NO __________If covered, specify the source, amount, and coverage period of the insurance:Source: ______________________________Amount: $ _________________CoveragePeriod:______________________________9512WFP1

Section IIDISPLAY OPERATOR INFORMATION: (Note: This is to be completed by the individualwho will shoot and/or discharge the fireworks or pyrotechnics.)Name: ______________________________ Telephone: ____________ homeAddress: ______________________________ ____________ work____________________________________________________________Display Operator Permit Number (NC OSFM) ___________________________________________Bureau of Alcohol, Tobacco and Firearms permit/license type and no.: _____________________Specify Pyrotechnicians’ training and experience:_______________________________________________________________________________________________________________________________________________________________________________________________________________Indicate whether the technician is or will be insured with respect to the discharge offireworks/pyrotechnics: YES __________ NO __________If covered, specify the source, amount, and coverage period of the insurance:Source: ______________________________Amount: $ ____________________CoveragePeriod:______________________________Assistant Display Operators _______________________________ Permit #_______________________________________________________________________________________________________________________On-site Assistants______________________________________________________________________________________________________________________________________________________________________________9512WFP1

Section IIIDISPLAY INFORMATION: (Note: Indicate who provided this information:)Applicant: __________ Technician: __________ Both: __________Indicate the type of display event:Carnival: __________ Exhibition: __________ Fair: __________Public Celebration: __________ Other: __________Proposed day and time of the event: ___________________________________________________Day: ______________________________ Time: _________________________ AM / PMProposed location or site:_________________________________________________________Specify the type and quantity of the fireworks/pyrotechnics to be used and the sequence of thedischarge/shooting:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Estimated duration of the display:____________________________________________________Specify any safety precautions to be taken: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Specify how fallout area will be inspected for unexploded or live components (This inspectionshall be conducted prior to any public access): ___________________________________________________________________________________________________________________________________________________________________________________________________________________9512WFP1

Section IVPUBLIC SAFETY INFORMATION:The display will occur within the following fire district:______________________________Location of the nearest fire station:______________________________Name and location of the nearest medical facility:Name: ______________________________ Location: ______________________________Section VI certify under penalty of perjury that the foregoing information which I have provided is trueand accurate to the best of my personal knowledge._____________________________Applicant_______________Date______________________________Display Operator_______________DateSworn to and subscribed beforeSworn to and subscribed beforeme this ____________________me this ____________________day of __________ , _______ . day of __________ , _______ .______________________________Notary Public______________________________Notary PublicMy commission expires:______________________________My commission expires:______________________________9512WFP1

Section VIFIRE DEPARTMENT COMMENTS: (Note: To be completed by the local fire departmentrepresenting the district in which the discharge will take place.)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Recommendation:Approve: ____________ Disapprove: ____________Chief’s Signature: ______________________________ Date: ______/_______/_________FOR OFFICE USE ONLYSection VIIFIRE MARSHAL COMMENTS:________________________________________________________________________________________________________________________________________FINAL APPROVAL: Approved: __________ Disapproved: __________Conditional approval and/or special conditions:___________________________________________________________________________________________________________________________Fireworks Permit No. ____________Section VIIIPermit applications may be submitted in person weekdays from 8:30 a.m. to 5:00 p.m., ormailed to:Wake County FinanceWake County Justice Center301 S. McDowell St - Suite 2900Raleigh NC 27601Accounts.Receivable@wakegov.comPermit fee - $100.00 per displayFinance Department Use Only:Date Received: Check #: Receipt #:9512WFP1