Form IN-0053 "Application for Display of Fireworks/Pyrotechnics/Flame Effects Permit" - Tennessee

What Is Form IN-0053?

This is a legal form that was released by the Tennessee Department of Commerce and Insurance - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2018;
  • The latest edition provided by the Tennessee Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IN-0053 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Commerce and Insurance.

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Download Form IN-0053 "Application for Display of Fireworks/Pyrotechnics/Flame Effects Permit" - Tennessee

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FOR OFFICE USE ONLY
LICENSE TYPE
4504____
NEW ENTITY NUMBER ________________
ALL FUNDS GO ON NEW ENTITY
500 James Robertson Parkway
Nashville, TN 37243
Tel: 615-741-2981
http://www.tn.gov/commerce/
APPLICATION FOR DISPLAY OF FIREWORKS/PYROTECHNICS/FLAME EFFECTS PERMIT
Applications received by the State Fire Marshal’s Office within ten (10) or fewer days prior to the
display date must pay an expediting fee of fifty dollars ($50) in addition to the permit fee.
A permit is required for all outdoor fireworks displays regulated by National Fire Protection Association
(“NFPA”) 1123, all proximate pyrotechnic displays regulated by NFPA 1126, and all flame effect displays
regulated by NFPA 160.
INSTRUCTIONS:
1. For Individual displays, a fifty-dollar ($50) fee must be submitted. Displays extending beyond one (1) day
or occurring at multiple locations, and not meeting the requirements stated in item 3 require a separate
permit for each day (including a separate application and fifty-dollar ($50) fee for each permit).
2. Multiple displays that are exactly the same in regard to display pieces, firing locations, setup, emergency
vehicle locations, audience locations, etc., require one permit and a fifty-dollar ($50) fee per display up
to a maximum fee of four-hundred dollars ($400). The permit is valid for one (1)-year from the date of
issuance.
3. All permit applications for public fireworks display must be in writing and received in the State Fire
Marshal’s Office at least 10 or more days before the date of the proposed display. However, the State
Fire Marshal may accept applications and issue permits within the ten (10)-day window of the display
date. There will be a $50 expediting fee for submissions within this ten (10)-day window (in addition to
the regular permit fee).
4. Payment shall be submitted along with the application to the Department of Commerce and Insurance.
Please note that payment of fee does not guarantee issuance of permit.
5. The chief supervisory official of the fire department(s) must sign the application in the space provided.
You must also send written notification to the chief supervisory official of the municipality or chief law
enforcement official of the county, depending on the site of the display. You must state the date, time
and location of the public display.
6. Submit a copy of your current Certificate of Liability, with the State of Tennessee listed as the certificate
holder or additional insured.
7. All applications will be reviewed by the Codes Enforcement section for compliance with codes and
standards. Deficiencies must be corrected prior to issuance of the permit.
8. Alterations or revisions submitted after the original permit is issued may require a new permit application
and fee.
Applicant: The sponsor or an individual representing the sponsor. Permits are issued and mailed to the
applicant.
Any person or organization that contracts with a licensed exhibitor and certified operator to
Sponsor:
perform a display.
Exhibitor: A business licensed by the state to perform displays or provide flame effects, fireworks or
pyrotechnic materials for displays.
Operator: An individual who by experience, training and examination by the state, has demonstrated the
necessary knowledge and ability to use and supervise fireworks, pyrotechnics, or flame effect
displays.
IN-0053 (Rev. 11/18)
Page 1 of 3
RDA 2225
FOR OFFICE USE ONLY
LICENSE TYPE
4504____
NEW ENTITY NUMBER ________________
ALL FUNDS GO ON NEW ENTITY
500 James Robertson Parkway
Nashville, TN 37243
Tel: 615-741-2981
http://www.tn.gov/commerce/
APPLICATION FOR DISPLAY OF FIREWORKS/PYROTECHNICS/FLAME EFFECTS PERMIT
Applications received by the State Fire Marshal’s Office within ten (10) or fewer days prior to the
display date must pay an expediting fee of fifty dollars ($50) in addition to the permit fee.
A permit is required for all outdoor fireworks displays regulated by National Fire Protection Association
(“NFPA”) 1123, all proximate pyrotechnic displays regulated by NFPA 1126, and all flame effect displays
regulated by NFPA 160.
INSTRUCTIONS:
1. For Individual displays, a fifty-dollar ($50) fee must be submitted. Displays extending beyond one (1) day
or occurring at multiple locations, and not meeting the requirements stated in item 3 require a separate
permit for each day (including a separate application and fifty-dollar ($50) fee for each permit).
2. Multiple displays that are exactly the same in regard to display pieces, firing locations, setup, emergency
vehicle locations, audience locations, etc., require one permit and a fifty-dollar ($50) fee per display up
to a maximum fee of four-hundred dollars ($400). The permit is valid for one (1)-year from the date of
issuance.
3. All permit applications for public fireworks display must be in writing and received in the State Fire
Marshal’s Office at least 10 or more days before the date of the proposed display. However, the State
Fire Marshal may accept applications and issue permits within the ten (10)-day window of the display
date. There will be a $50 expediting fee for submissions within this ten (10)-day window (in addition to
the regular permit fee).
4. Payment shall be submitted along with the application to the Department of Commerce and Insurance.
Please note that payment of fee does not guarantee issuance of permit.
5. The chief supervisory official of the fire department(s) must sign the application in the space provided.
You must also send written notification to the chief supervisory official of the municipality or chief law
enforcement official of the county, depending on the site of the display. You must state the date, time
and location of the public display.
6. Submit a copy of your current Certificate of Liability, with the State of Tennessee listed as the certificate
holder or additional insured.
7. All applications will be reviewed by the Codes Enforcement section for compliance with codes and
standards. Deficiencies must be corrected prior to issuance of the permit.
8. Alterations or revisions submitted after the original permit is issued may require a new permit application
and fee.
Applicant: The sponsor or an individual representing the sponsor. Permits are issued and mailed to the
applicant.
Any person or organization that contracts with a licensed exhibitor and certified operator to
Sponsor:
perform a display.
Exhibitor: A business licensed by the state to perform displays or provide flame effects, fireworks or
pyrotechnic materials for displays.
Operator: An individual who by experience, training and examination by the state, has demonstrated the
necessary knowledge and ability to use and supervise fireworks, pyrotechnics, or flame effect
displays.
IN-0053 (Rev. 11/18)
Page 1 of 3
RDA 2225
FOR OFFICE USE ONLY
LICENSE TYPE
4504
NEW ENTITY NUMBER ___________
ALL FUNDS GO ON NEW ENTITY
APPLICATION FOR DISPLAY OF FIREWORKS/PYROTECHNICS/FLAME EFFECTS PERMIT
(Pursuant to Tenn. Code Ann. § 68-104-201 et al.)
Please type or print all information. All fields below are required, and failure to answer any field below will result in
the application being returned unprocessed. Please note that you may complete the following form online at
https://core.tn.gov. Completing the form online will allow you to pay by credit card. If you choose to fill out the
paper form, please mail the completed form with a check or money order to: Tennessee Department of
Commerce & Insurance, 500 James Robertson Parkway, Division of Fire Prevention, Permits & Licensing
Section, 500 James Robertson Parkway, Nashville, TN 37243. The check or money order should be made
payable to the Department of Commerce and Insurance. For questions regarding this application or the permit,
please contact the Permits and Licensing Section at (615) 741-2981.
APPLICANT
Name:
Mailing Address:
City: _______________________ County: ____________________ State: ______ Zip:
Phone #: (
) ___________________ Email Address:
SPONSOR
Name:
Mailing Address:
City: _______________________ County: ____________________ State: ______ Zip:
Phone #: (
) ___________________ Email Address:
I have submitted the following permit fee with this application (check all that apply):
Individual Display Fee ($50)
Multiple Display Fee ($400 max)
Expediting fee for permits received by State Fire Marshal’s Office within 10 days of display ($50, in
addition to permit fee)
Name of Display:
Location of Display:
Street Address
City
County
Zip
Date(s) and Time(s) of Display:
Tennessee Licensed Exhibitor:
Name of Exhibitor
Tennessee License No.
Tennessee Certified Operator(s):
Operator Name
Tennessee Certification No.
Operator Name
Tennessee Certification No.
Operator Name
Tennessee Certification No.
IN-0053 (Rev. 11/18)
Page 2 of 3
RDA 2225
FOR OFFICE USE ONLY
LICENSE TYPE
4504
NEW ENTITY NUMBER ___________
ALL FUNDS GO ON NEW ENTITY
Please select the type(s) of display(s):
Outdoor Fireworks (NFPA 1123)
Proximate Pyrotechnics (NFPA 1126)
Flame Effects (NFPA 160)
Please select the types of fireworks/pyrotechnics to be used:
1.3
1.4G
1.4S
Consumer or common
Please list the types of fireworks (including mortar sizes), pyrotechnic devices, and/or flame effects to be
used at the display(s), using additional paper if necessary:
By signing below, I certify that I am familiar with Tenn. Code Ann. Title 68, Chapter 104, Part 2, and the
Rules and Regulations issued pursuant thereto. I further certify that all information provided herein is correct.
_____________________________________________________
______________________
Signature of Applicant
Date
______________________________________________________________________________________
SIGNATURE OF CHIEF SUPERVISORY OFFICIAL
Please note that the permit will not be issued without the signature below. Please print or type legibly.
If the proposed display is to be performed within the limits of a municipality, submit the signed approval of
the chief supervisory officials of the fire department of such municipality. If the proposed display is to be
performed within the limits of a county, but outside the limits of a municipality, submit the signed approval of
the fire department officials of such county, or such officials’ designee.
I, _________________________________________________, Chief Supervisory Official of the Fire
Department of the City/County of ________________________________, hereby approve this application.
_____________________________________________________
______________________
Signature of Official of Fire Department
Date
IN-0053 (Rev. 11/18)
Page 3 of 3
RDA 2225
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