2. Applicant Information
4. Application Date*
   Application Date
5. Applicant First Name*
6. Applicant Last Name*
8. Email*
9. Applicant Contact Phone Number*
10. Applicant Contact Phone 2 (Optional)
12. Address1
14. City
15. State
16. Zip
20. Location Information
22. Site Name*
23. Owner / Manager Name*
25. Owner/Manager Email*
26. Owner / Manager Contact Number*
28. Site Address*
30. City*
31. State*
32. Zip*
34. Operation Start Date*
    Operation Start Date
35. Operation End Date*
    Operation End Date
37. Application is hereby made by the undersigned for a PERMIT to conduct the following: *
    Please describe
39. I HEREBY ACKNOWLEDGE that the information contained herein, and DECLARE that it be true and correct, to the best of my knowledge and belief. Further, I am the OWNER/OPERATOR, or a duly authorized AGENT acting on behalf of the OWNER, for all activities at the above referenced property or location. As such, I hereby agree to comply fully with all requirements Virginia Statewide Fire Prevention Code and the City of Waynesboro Fire Prevention Code governing the operation I wish to conduct. Failure to provide complete and accurate information shall be just cause for revocation. Applicant is responsible for scheduling required inspection(s) prior to the issuance of permit.*

    1. Agree
    2. Disagree
41. Fire Prevention Code Permit Information
    Permit Information
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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