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PYROTECHNICS PERMIT CHECKLIST-- Blue CrosslBiue Shield Family Day 2004 North Carolina General Statue 14-413 empowers County Commissioners in the State to issue permits for the use of pyrotechnics in connection with shows of ali descriptions after satisfactory evidence is produced to the effect that the pyrotechnics will be used for the aforementioned purposes and no others. The Orange County Commissioners have adopted a policy which cites the completion of the following criteria as prerequisite to the Issuance of a pyrotechnics permit. Verification of the receipt of information will be evidenced by the signature of the appropriate ofFicial on this form. Only after all criteria listed below have been met will the permit be issued. It should be further noted that aii signatures must be written on the face of the permit in order for the permit to be valid. Penalties for use of pyrotechnics without a permit are cited in the North Carolina Building Code, Administration and Enforcement, Volume 1A, Chapter 8.1. CRITERIA APPROVED BY DATE 1. LETTER OF REQUEST RECEIVED FROM SPONSORING AGENCY Yes 429-04 2. FIRE DEPARTMENT CONFIRMED ADEQUATE FIRE PROTECTION Yes/Town of Chapel Hili 4-29-04 MEASURES WILL BE OBSERVED AT EVENT. Fire Departrnent 3, LAW ENFORCEMENT CONFIRMED THAT ADEQUATE MEASURES YesRown of Chapel Hili 4-29.04 WILL BE IN PLACE TO ENSURE PUBLIC SAFETY DURING EVENT, 4, QUALIFICATIONS0..ICENSE SUBMITTED FOR PYROTECHNIC Approved by Town of 4-29-04 OPERATOR Chapel Hili Fire Dept. 5. SITE LAYOUT SUBMITTED BY THE PYROTECHNIC OPERATOR. Town of Chapel HIII FIre 4-29-04 De 1. 6.. INVENTORY OF PYROTECHNICS TO BE USED SUBMITTED Wili be approved by Town 4-2904 of Chapel Hili FIre Dept on da of dis la 7. CERTIFICATE OF INSURANCE FOR GENERAL LIABILITY COVERAGE Pam Jones reviewed, 4-2904 RECEIVED; MUST INCLUDE COUNTY AS A NAMED INSURED ON THE Names County as FACE OF THE CERTIFICATE; MINIMUM LIMIT $1,000,000 PER Additlonal Insured as PERSON/PER OCCURRENCE, reugired; arxeptabe limits 8, LOCATION OF PYROTECHNIC DISPLAY HAS CURRENT FIRE YeslTown of Ghapel Hiil, 4-2904 INSPECTION AND IS IN COMPLIANCE WITH THE STANDARD FIRE PREVENTION CODE, 1988, WITH NORTH CAROLINA AMENDMENTS. 9. SHOW SET UP HAS BEEN APPROVED 8Y THE FIRE OFFICIAL IN Chapel Hili has approved, 4-2904 APPROPRIATE JURISDICTION PRIOR TO THE BEGINNING OF oontlngent upon County SHOW. a rovai CERTIFICATION RESPONSIBILITIES: ITEMS 1d: ORANGE COUNTY DIRECTOR OF PURCHASING AND CENTRAL SERVICES or ORANGE COUNTY DIECTOR OF EMERGENCY MANAGEMENT OR DESIGNATE. ITEM 8: JURISDICTION'S FIRE OFFICIAL ITEM 9: ORANGE COUNTY DIRECTOR OF EMERGENCY MANAGEMENT OR DESIGNATE" NOTE: THIS SIGNATURE CERTIFIES THAT THE FIRE OFFICIAL IN THE APPROPRIATE JURISDICTION HAS MADE THE SETUP INSPECTION. IT IS NOT INTENDED TO INDICATE THAT THE COUNTY'S EMERGENCY MANAGEMENT DIRECTOR MUST INSPECT AND APPROVE SET UP PERSONALLY. FOLLOWING CERTIFICATION OF ITEM 9, PLEASE RETURN THIS FORM TO THE PURCHASING AND CENTRAL SERVICES DIRECTOR.