OFFICE OF THE STATE FIRE MARSHAL 2401 N.W. 23rd Street, Suite 4 Oklahoma City, OK 73107 405 522-5005 FAX: 405 522-5028 APPLICATION FOR PERMIT PYROTECHNICS BEFORE A PROXIMATE AUDIENCE

I hereby make application for a permit to conduct a Pyrotechnics before a Proximate Audience display as defined by the Oklahoma State Fire Marshal Commission, and agree to comply with the laws pertaining to those set forth in the state statutes and by the National Fire Protection Association (NFPA) 1123, 1126 & 160, 2010 Editions, as adopted by the Oklahoma State Fire Marshal Commission.

Applicant: Phone:

Address: City: State: Zip:

Location of Display:

Address: City:

County: Zip:

Responding Fire Department:

Date of Display: Time of Display:

Sponsor’s Name: Sponsor’s Address:

City: State: Zip: Phone #:

Name of Authorized Contact Person: Phone #:

Name of Operator: Phone #:

Number of Shows Shot in the Last 12 Months: Number of Shows Shot in the Last 5 years:

Page 1 of 4 Form updated 5/13/2013 all other previous forms are obsolete. Manner and Place of Storage of Pyrotechnic Material:

Type and Number of Pyrotechnics to be Discharged:

1. 6.

2. 7.

3 8.

4. 9.

5. 10.

Flame Effect will be used: Yes No (check one) The Display will be fired: Manually Electrically Combined (check one) Insurance Carrier: Phone #: Address: City: State: Zip:

Required fees and documentation to be included with the completed application is as follows:

 A site diagram of the area where the display will take place. If the site diagram is incomplete this may delay the issuance of a permit. The diagram is not required to be to scale but must include the following: 1. The point at which the proximate fireworks are to be positioned and fired. 2. The fallout radius for each proximate fireworks used in the display. 3. The lines behind which the spectators are restricted indicating distances in feet.

 Copy of the certificate of liability insurance with policy limits in an amount of no less than one million dollars ($1,000,000)

 Copy of the U.S. Bureau of Alcohol, Tobacco, Firearms and Explosives license/permit.

 Copies of certification that the set, scenery, and rigging materials meet required flame retardant standards or have been treated to achieve the flame retardant standards.

Page 2 of 4 Form updated 5/13/2013 all other previous forms are obsolete.  Fee to be paid by check, money order or bank draft in the amount of $250.00 and payable to the Office of the Oklahoma State Fire Marshal.

 Material safety data sheets (MSDS) for the pyrotechnic material to be used.

The application, required documentation and fee amount must be submitted together to the Office of the Oklahoma State Fire Marshal at least 10 working days prior to date of display. Any deviation from these instructions could result in the delay or denial of said permit.

Prior to any approval of display a site inspection with pyrotechnic walkthrough and demonstration is required.

In accordance with the Oklahoma Fire Marshal Commission adopted Rules and NFPA 1123 & 1126, the undersigned hereby requests issuance of permit for the presentation where pyrotechnic effects are used indoors or outdoors with a proximate audience.

I, the undersigned attest and ATTACH TO THIS REQUEST, PROOF OF INSURANCE, that Pyrotechnic liability insurance protection is provided in the minimum of $1,000,000 as coverage for the location described on the permit, that NFPA 1123, 1126 and 160 safety precautions shall strictly be observed, and that information on this permit is true and correct.

Representing (Signature) (Company Name)

STATE OF , COUNTY OF Before me, the undersigned, a Notary Public in and for said State on this day of , personally appeared , To me known to be the identical person. Given under my hand and seal the day and year last above written.

Notary Public My Commission Expires

(Seal)

This permit is not transferable and is issued contingent on the above conditions.

By: Oklahoma State Fire Marshal Commission Page 3 of 4 Form updated 5/13/2013 all other previous forms are obsolete. ISSUED AT OKLAHOMA CITY, OKLAHOMA, THIS DAY OF ,

This permit is not valid unless it bears the seal of the Office of the State Fire Marshal. In the event of postponement of the display, this Permit is valid for three (3) days from the display date set forth above.

One complete notarized original application (3pages) must be submitted with insurance verification to the State Fire Marshal’s Office.

Page 4 of 4 Form updated 5/13/2013 all other previous forms are obsolete.