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2. 
3. Franklin County Department of Public Safety
   Application for Permits
   

   PERMITS ARE $75.00 EACH

   Payments can be made in person or mailed to:
   
   Franklin County Public Safety
   50 Claiborne Ave.
   Rocky Mount, VA 24151

5. Includes Amusement Building, Assembly (Church, Restaurant, Harvester, Etc.), Commercial Burning, Commercial Cooking, Explosive Blasting Storage, Fireworks Ariel Display, Fireworks Retail, Fireworks Mercantile, Food Trucks, Hazardous Material, LP Gas Refill, Occupancy Permit, Social Service Licenses, Scrap Tires or byproducts (250 or more)

7. Type of Permit*
   -- Select One --Amusement BuildingAssembly (Church, Restaurant, Harvester, etc.)Commercial BurningCommercial CookingExplosive Blasting Storage/Application & Permit to Use ExplosivesFireworks Arial DisplayFireworks RetailFireworks MercantileFood TruckHazardous MaterialLP Gas RefillOccupancy PermitSocial Service LicensesScrap Tires or Byproducts (250 or more)
9. Business Name*
10. Business Address*
12. City*
13. State
14. Zip Code
16. Contact Person*
17. Phone Number*
19. Email Address*
21. Location?*
23. You chose a type of Fireworks Permit. You must list supplier name and contact information*
25. Please list any additional information here
27. Will the blasting operation utilize any prohibited explosives as listed in Virginia Construction Code, National Fire Prevention Code and the Statewide Fire Prevention Code?*

    1. Yes
    2. No
28. You answered YES to the previous question, please explain:*
30. Which type of air blast and ground vibration monitoring will apply to the blasting operation?*

    1. Table Standards per Section 5607, State Fire Prevention Code
    2. Seismographic instrumentation per Section 5607, State Fire Prevention Code
31. Will blasting operations and procedures be conducted in compliance with Virginia Construction Code, National Fire Prevention Code and the Virginia Statewide Fire Prevention Code including any addendums applicable at the issuance of this permit?*

    1. Yes
    2. No
33. Physical location where explosives are to be used and type of blasting to be done?*
35. List certification number of blaster assigned to project or job.*
37. Project/Job Start Date:*
    Project/Job Start Date:
38. Project/Job End Date - Permit is good for 30 days.*
    Project/Job End Date - Permit is good for 30 days.
40. It is acknowledged and agreed that a condition of permit issuance is use of the explosives in accordance with the Virginia Satewide Fire Prevention Code now in effect. Attached is proof of liability insurance as described in Section 5603. Please attach here!*
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Electronic Signature
48. Signature of Fire Marshal

    __________________________________________________________________________________

49. Date Fire Marshal Signed

    ______________________________________

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field