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2. Name/Company*
3. Street Address*
5. City *
6. State *
7. Zip*
8. Phone*
10. Representative Applying *
11. 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
12. Please Explain
14. 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
15. 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
17. Physical location where explosives are to be used and type of blasting to be done.*
18. List certification number of blaster assigned to project or job.*
20. Project/Job Start Date*
    Project/Job Start Date
21. Project/Job End Date - Permit renewal available after 12 month max*
    Project/Job End Date - Permit renewal available after 12 month max
22. It is acknowledged and agreed that a condition of permit issuance is use of the explosives in accordance with the Virginia Statewide Fire Prevention Code now in effect. Attached is proof of liability insurance as described in Section 5603.* Please attach here!
24. Electronic Signature Agreement

    *By typing your name, you are certifying that you have read and agree with the following statement in its entirety. I agree that my typed name on this document is the legally binding equivalent to my handwritten signature. I will not, at any time in the future, repudiate the meaning of this signature or claim that this signature is not legally binding.

    1. I agree.
26. Electronic Signature*
27. Date*
    Date
29. This permit becomes valid when signed by the local fire official and a valid permit number is assigned.
    
31. OFFICE USE ONLY
    

    Signature of Fire Marshal & Date:

    ___________________________________________________________________

    *NOTES*

    
    

    
    

    
    

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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