Fireworks Permit, CampbellHarnett
COUNTY
..
n Review,. Inspection,. and Permit Fees
Application Number
17-50042153
$200.00
❑
Explosive Material (90 Days)
$ -
$100.00
❑
Explosive Materials (72 Hours)
$ -
$100.00
2
Fireworks Public Display
$ 600.00
$50.00
❑
Final Inspection
$ -
$35.00 + $2.00 per device
❑
Fire Alarm Testing
$ -
$35.00 + $2.00 per nozzle
❑
Fixed Fire Suppression
$ -
$75.00
❑
Insecticide Fog/Fumigation
$ -
$100.00
❑
Pipe Test/UST/AGST
$ -
$50.00
❑
Plans up to 5000 sq ft
$ -
$100.00
❑
Plans 5001 sq ft to 10,000 sq ft
$ -
$150.00
❑
Plans 10,001 sq ft to 25,000 sq ft
$ -
$250.00
❑
Plans 25,001 sq ft and over
$ -
$35.00 + 2.00 per head
❑
Sprinkler Certification Test
$ -
$50.00
❑
Standpipe Testing
$ -
$50.00
❑
Special Assembly
(ie. amusement buildings, carnivals, fairs)
$ -
$75.00
EJ
Tents/Canopies/Air Supported Structure
$100.00
El
Tank Installation (charge for each tank)
$ -
$100.00
❑
Tank Removal (charge for each tank)
$ -
Total Devices/Heads
$ -
Total Cost
$ 600.00
Code Enforcement Official
Rodney Daniels
8/29/2017
Harneft
COUNTY
u.
2a
Fire Marshal Division
August 29, 2017
Tom Thompson
East Coast Pyrotechnics
PO Box 209
Catawba, SC 29704
Re: Application Number: 17-50042153
Campbell University Football Game Fireworks
Mr. Thompson,
Thank you for submitting the fireworks application to our office. I have reviewed the
submittal package and approved the request based on the information provided. The
following notes are provided for your information.
® This is a blanket application for the following requested dates. A separate permit
will be issued on each event date.
o August 31, 2017 at 7:OOpm
o September 09, 2017 at 6:OOpm
o September 30, 2017 at 2:OOpm
o October 7, 2017 at 2:OOpm
o October 28, 2017 at 2:OOpm
o November 11, 2017 at 1:OOpm
® All firework displays shall comply with the following:
Section 3308 NCSFC
NFPA 1123 and/or NFPA 1126
m A representative from the Fire Marshal's office will inspect and issue the required
permits prior to the display. Please schedule an inspection with this office prior to
each game.
If I can be of further assistance please do not hesitate to contact me. We look forward
to working with you and your staff.
Sincerely,
Rodney D iels
Chief Deputy Fire Marshal
IT SZ)o q ZI � 3
Harnett ------
COUNTY
MIORT" MNA
(4
Fire Marshal Division
Attached you will find an application for a Fireworks Discharge Pen -nit. This application must be
completed and returned to Central Permitting prior to issuance of [lie permit. PLEASE ALLOW
FIVE (7 -10) WORKING DAYS FOR PROCESSING.There is a25,00 pennit fee assessed
per discharge event,issuanceerra�Ifyou have any
questions, please feel five to contact us,
ITE RE -Q U I R �r-
,D PRI(JR To
MS p rRpj I T I S Lj,� N C 1',,
f . °til blanks must be coni feted ori tl�e a lic-anon.
The Permit Holder is required to obtain liability insurance in an amount sufficient
to cover the claims of any person(s) who may f)e injured or otherwise damaged as
a result of the display. The insurance must name Harnett County as an additional
insured and a copy of the Certificate of Insurance evidencing the coverage must
accompany the application, ( Amounts will be determined by event
1 Include a detailed site plan indicating the discharge and storage locations and
distance.
Include the manufacturer's teclinical data sheet of each type of pyrotechnics to be
discharged,
SEC110N EXPLANATIQN,
Section 1: Information on the person, group, corporation, association, or entity,
sponsoring, holding, or primarily responsible for the event
Section 11: Information on the Pyrotechnic ian
Section III: Information on the actual display
Section IVPublic Safety Information, (Name of fire district where the discharge will
take place, address of the nearest fire station, and name and location of the
nearest medical facility.)
Section V; Notarization of the application, (APPLICATION SIGN. TURl"S MUST BE
No'EARIZED. )
Section VI: Fire Department Comments, (This must be completed by the Chief of the
local fire, department representing the district where the discharge will
take place
Section VII: For Harnett County Fire Marshal use only
Section VIII: Fireworks Pen -nit Number,
THE FIRE -WORKS PERNIFF MU,S'I' BE ON SITE DURING THE DISCHARGE OF
THE PYROTECHNICS,
'Marnett
MCOU14TY
A71,d
IMPORTANT: THIS APPLICATION MUST BE RETURNEDINCA T> `i THAN FIVE
(5) WORKING DAYS PRIOR iO FT -ENT TO ENSURE PERMIT PROCESSING.
PLEASETYPE OR PRINT
APPLICANTINFORMATION: (Note: The applicant is the person, group. corporation.
7 --
association, or other entity sponsoring, holding or primarily responsible for the event or enterprise
for which this permit is requested.)
Name: East Coast Pyrotechnics - Telephone: 803-789-5733 horne
I
Address: 0 Box 209 803-789-5733 work
Catawba, SC 29704
For a corporate applicant, indicate the name and address of the registered agent for
service of process:
Name: Joel Matthews tjoe1@eastcoastpyro,com_._____
Address: P.O. Box 209
President or
CM Tom Thompson
Indicate whether the applicant is or will be insured with respect to the discharge of
fireworks/pyrotechnics: YES XX NO
If covered, specify the source, amount, and coverage period of the insurance:
Britton -Gallagher & AsSOC Amount: $ 5,0M000,00
Source,-----,---------- -
M
Harneft
CUNTY
;77777777-
_*
OA&
PYROTECHNICS TECHNICIAN INFORMATION: (Note: This is to be completed by
the individual who will shoot and/or discharge the fireworks or pyrotechnics.)
Name:- Rodney Eason Telephone: (910) 237-2298 home
Address: 694 Miller Road (910) 237-2298
work
Benson, NC 27504
Bureau ofAlcohol, 'robacco and Firearms perrint/license tve and no.: I SC_09i-51�9E-W223
p
Specify Pyrotechnicians* training and experience:
NC Licensed Operator #3025, over 7 years experience. Past displays
Campbell University and NC State University
Indicate whether tile technician is or will be insured with respect to the discharge of
reworks pyrotechnics: YES _XX NO
Ifcovered, specify the source, amount, and coverage period of the insurance:
Source: Britton -Gallagher & Assoc Amount: S 5,00"00,00
DISPLAY INFORMATION: (Note: Indicate who provided this information:)
Applicant: XX Technician' Both
Indicate the type of display event:
Carnival: Exhibition: Fair:
Public Celebration: ____ Other: XX Proposed day and time of the event:
8131, 9/9� 9/30, 10/7, 10/28 & 11/11/2017 various - see below
Ir v: Time: AM / PM
Proposed location or site: Campbell University / Baker -Lane to int attached)
Specify the type and quantity of the fireworks/pyrotechrues to be used and the sequence
of the discharge/shooting:
(48) 30mm x 50 foot "Close Proximity" Mines
8/31 @ 7:00pm, 9/9 @ 6-OOpm, 9/30 @ 2:00prn
10/7 @ 2.�OOpm, 10/28 @ 2:00pm, 11/11 #!
Hamett
N T Y
'IL1011 01 UIC Ur,77r7,
15 to 30 seconols
Specify any safety precautions to be Laken:
Follow all NEPA 1126 , State of North Carolina and Harnett County
ME=
PUBLIC SAFETYMORMATION:
The display will occur within the following fire district:
Buies Creek
Location of the nearest fire station: Buies Creek VFD, 112 Marshbanks St
Name and location of the nearest medical facility.
Name: Central Harnett Hospital Location: Lillington, NC
Harnett
COU N TYc.
*0*1�1 CARD- M4
FIRE DEPARTMENTCOMMENTS � (Note: To be completed by local fire department
representing the district in which the discharge will take place,)
Recommendation:
FINAL APPROVAL: APPROVED: I--- DISAPPROVED:
Conditional approval and/or special conditions:
Fireworks Pernin, No. -ft-75�00
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PRODUCER
Britton Gallagher AWL
PHONE FAX
One Cleveland Center, Floor 30 ----- ----- -
ftAIL
1375 East 9th Street
Cleve -land OH 44114 (S)AFFORDNG COVERAGE --
P. OBox 22 IN D-Everest,National..Insura,.nce-Comp-any-,
Catawba SC 29704
!NSUJ
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OVERAGES CERTIFICATE NUMBER: 1 8932223 REVISION NUMBER:
THIS IS TO CERTfFY TFIAT THE LISTED BELOW HAVE BEEN 1S--SUE5 TO THE INSURED NAMED ABOVE FOR THE P�PEPIOD
INDICATED, t+ OTVATHSTANDiF:G ANY REQUIRE ENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO OMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO :ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
PMMY-EFF -POLICY EXP
POL9CY ECU ErC ft$k$�'iCtr'YYYY - T#I%�r�fYYYY Ldi4iT5
GENERAL i fASf :tTY A SI#r 1L. :. a-171 3,1012017M,'201$
EACH WUCURRENCE $1,000,000 .�
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DESCRIPTION OF OPERATIONS I LOCATIONS F VEHICLES (AU=h ACORD 11H. Addiftrial ReseWks Schedu€e, it more space is requirIm)
Additional Insured extension of coverage IS provided babove referencedGenera[ Liability policy where required by written agreement
FIREWORKS ORKS DISPLAY PATES. AUGUST 1, 2017 SOTEP EER 9,30,2017; OCTOBER 7, 28, 2017, NOVEMBER 11, 2017
ADDITIONAL INSURED: 1}CAMPBELL UNIVERSITY INCORPORATED, TED, 2)HARNETT COUNTY
UtKI€J AI t HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CAMPBELL UNIVERSITY INCORPORATED THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 97 ACCORDANCE WITH T14E POLICY PROVISIONS.
SAPS CREEPS NC 27506
AtTHOR#T,ED REPRESENTATIVE
9988-20itt ACORN CORPORATION, All rights reserved.
ACR 5 (2514188) The ACORD name and Pogo are registered marks of ACORD
NCD0l OSFM I Fire Safety Programs - Code Officials Pyrotechnic License I L. 11age I of 2
S.
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r1R9 SAPITY PROGRAta - PYROTECHNIC LICENSE INFOPHATION
PYrotechn.1c License Information
Current Pyrotechnic License Holders
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