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2 <br />PYROTECHNICS PERMIT CHECKLIST <br />Blue Cross/Blue Shield Family Day 2006 <br />North Carolina General Statue 14.413 empowers County Commissioners in the State to Issue <br />permits for the use of pyrotechnics in connection with shows of ail descriptions after satisfactory <br />evidence is produced to the effect that the pyrotechnics will be used for the aforementioned <br />purposes and no others. <br />The Orange County Commissioners have adopted a policy which cites the completion of the <br />following criteria as prerequisite to the issuance of a pyrotechnics permit. Verification of the <br />receipt of information will be evidenced by the signature of the appropriate official on this form. <br />Only after all criteria listed below have been met will the permit be issued. it should be further <br />noted that ail signatures must be written on the face of the permit in order for the permit to be <br />valid. Penalties for use of pyrotechnics without a permit are cited in the North Carolina Building <br />Code, Administration and Enforcement, Volume 1A, Chapter 8.1. <br />CRITERIA APPROVED BY DATE <br />1. LETTER OF REQUEST RECEIVED FROM SPONSORING AGENCY Yes 4-26-06 <br />2. FIRE DEPARTMENT CONFIRMED ADEQUATE FIRE PROTECTION Yes(fown of Chapel HIII 4.26.06 <br />MEASURES WILL BE OBSERVED AT EVENT. Fire Department <br />3. LAW ENFORCEMENT CONFIRMED THAT ADEQUATE MEASURES Yesrtown of Chapel Hill 4.26.06 <br />WILL BE IN PLACE TO ENSURE PUBLIC SAFETY DURING EVENT <br />4. QUALIFICATIONS/LICENSE SUBMIITED FOR PYROTECHNIC Approval by Town of 426-06 <br />OPERATOR Chapel Hill Fire Dept <br />5. SITE LAYOUT SUBMITTED BY THE PYROTECHNIC OPERATOR Approval by Town of 426-06 <br /> Cha el Hill Fire De t. <br />6. INVENTORY OF PYROTECHNICS TO 8E USED SIJBMITTEO Will be approved by Town <br /> of Chapel Hill Fire Dept on <br /> de of dis la <br />7. CERTIFICATE OF INSURANCE FOR GENERAL LIABILITY COVERAGE Pam Jones reviewed 4-26-06 <br />RECEIVED; MUST INCLUDE COUNTY AS A NAMED INSURED ON THE Names County as <br />FACE OF THE CERTIFICATE; MINIMUM LIMIT St,000,000 PER Additional Insured as <br />PERSONIPER OCCURRENGE.. required; acceptaba i(mits <br />8. LOCATION OF PYROTECHNIC DISPLAY HAS CURRENT FIRE Yeslrovm of Chapel Hill 4.26-06 <br />INSPECTION AND IS INCOMPLIANCE WITH THE STANDARD FIRE <br />PREVENTION CODE, 20001NTERNATIONAL FIRE CODE WITH NORTH <br />CAROLINA AMENDMENTS. <br />SHOW SET UP HAS BEEN APPROVED BY THE FIRE OFFICIAL IN <br />9 Chapel Hiil approval, 426-06 <br />. <br />APPROPRIATE JURISDICTION PRIOR TO THE BEGINNING OF contingent upon County <br />SHOW. a royal <br />CERTIFICATION RESPONS181LITIES: <br />ITEMS t-T: DIRECTOR OF MERIGENCY MANAGEMENTIOR DESIGNATE. L SERVICES or ORANGE COUNTY <br />REM 8: JURISDICTION'S FIRE OFFICIAL _ <br />ITEM 9: SIGNATURE CERTIDFIES THAT THE FIRE OFFICIAL IN THE APPROPR ATE JU SDICTION HAS MADE <br />THE SETUP INSPECTION- IT IS NOT INTENDED TO INDICATE THAT THE COUNTY'S EMERGENCY <br />MANAGEMENT DIRECTOR MUST INSPECT AND APPROVE SETUP PERSONALLY. <br />FOLLOWING CERTIFICATION OF ITEM 9, PLEASE RETURN THIS FORM TO THE PURCHASING AND <br />CENTRAL SERVICES DIRECTOR.. <br />