2. Applicant First Name*
3. Applicant Last Name*
5. Applicant Phone Number*
6. Applicant Email*
8. Venue Address1*
10. Venue Address2
12. City*
13. State*
14. Zip*
16. Designated Individual Name
    If different than Applicant
17. Designated Individual Contact Number
19. Check All That Apply

    1. For the use of pyrotechnics in theatrical, musical or similar productions before a proximate audience, performers, or support personnel.
    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.
    3. The rehearsal of any production in which pyrotechnics are used.
    4. The indoor use of pyrotechnics.
    5. The outdoor use of pyrotechnics at distances less than those required by NFPA 1123, Code for Fireworks Display, as referenced by Section 5608.2.2 of the Virginia Statewide Fire Prevention Code.

    Note: This application and any permit issued as a result do not confer approval to use flammable liquids and/or flammable gases in any performance or display. A separate application and permit is required for the use of flame effects before a proximate audience.
21. Date and Time
    Date and Time Start Date

    Date and Time Start Time

    —

    Date and Time End Date

    Date and Time End Time
23. Check this box if the firing of identical pyrotechnic materials or device setups will occur on multiple consecutive days (sequential dates).

    1. Multiple Days
24. If multiple days, list all the dates and times.
26. Pyrotechnician Name*
    Provide the name of the Pyrotechnician that will be in charge of firing the pyrotechnics.
27. Pyrotechnician Certification Number*
    Provide Virginia certification number of the Pyrotechnician that will be in charge of firing the pyrotechnics.
29. Pyrotechnician Certification Information
    Pyrotechnician
30. List the number and types of pyrotechnic devices or materials to be used (including name or type of device and DOT Class)*
32. Please attach a diagram of the grounds or facilities where the production is to be held
    Diagram should include: (1) the point at which the pyrotechnic devices are to be positioned and fired (2) the fallout radius for each pyrotechnic device used in the performance (3) the lines behind which the audience will be restrained (4) the point of on-site assembly of pyrotechnic devices
33. Please attach a material safety data sheet (MSDS) for the pyrotechnic material(s) to be used
    MSDS information should include: (1) the name, address and phone number of the manufacturer (2) whether it is to be used with any special considerations or cautions
35. Certification that the set, scenery, and rigging materials are inherently flame-retardant or have been treated to achieve flame retardancy.
    If applicable
36. Proof of a corporate surety bond or a public liability insurance policy
38. Acknowledgement*

    I attest the information provided is complete and accurate. I acknowledge and agree to comply with all applicable requirements of the Virginia Statewide Fire Prevention Code (SFPC) and the referenced NFPA 1126-11 standard governing the use, storage and firing of pyrotechnics, even those not specifically covered or expressed on this application. I also acknowledge that if a permit is issued it shall be valid only at the location listed on the application and for the specific date(s) and time(s) for which it is issued. If approved to proceed, I acknowledge that such approval is conditional upon continued compliance with the SFPC. I further acknowledge and understand that any SFPC violations identified after approval to proceed may result in denial of final permit issuance or immediate suspension or revocation of a permit.

    1. I agree
40. Additional Information
    Pyrotechnics Information
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field