Fire Dance Safety Sheet

Logistics

Building or location name:
Address:
Event Date:
Event Time:

Devices use in the performance

Fire Chain

Fire Fingers

Fire Staff

Fire Wands

Fire Fans

Fire Rings

Fire Stilts

Fire Art

Fuel Details

Type(s) of fuel

Amount of Fuel traveling to site

/ ______Ounce(s)
______Pint(s)
______Quart(s)
Amount of Fuel to be used during performance / ______Ounce(s)
______Pint(s)
______Quart(s)

Application Method

/ Soak Pour
Containment Method for Excess Fuel / Catch pot or pan
Other:

Fuel container(s)

No glass or drinking bottles.

Original product container

1 quart metal container

DOT certified container

Other (specify): ______

______

Safety Details

I , ______

We, ______

will have the following fire control methods present:

Fire Extinguisher:

2A10BC minimum rating. Quantity: ______

Water spray can

Wet towels

Other (specify): ______

Trained Safety Staff

Performance extinguishing method:

Burn out

Wet Towel

Smother

When the performance is complete, the used fire devices will be:

returned to their original container/carrying case

wrapped up in a tarp

other specify:

______

Performance area details:

Type of barricade if any:
Size of Fire Performance Space:
Distance from Audience:
Backdrops present? / yes / no
If so, what type?
Are drapes or backdrops fire retardant?
Certified retardant? / yes
yes / no
no
Are performers costumes fire retardant?
Certified retardant? / yes
yes / no
no

Permit Requirements

ڤ  Provide a plot plan illustrating the performance area (include all six zones of the performer: floor, ceiling, front, back, left and right sides).

ڤ  Provide a plot plan illustrating the location of the fire performer, safety perimeter line, and the audience.

ڤ  Provide proof of Insurance (1 million dollars) each time you apply for a fire permit.

ڤ  The insurance form shall also list the City and County of San Francisco and it’s employees as additional insured.

ڤ  Complete the permit application form and render permit fee at 698 2nd Street cross of Townsend Street. Hours are Monday through Friday

8 – 11 AM and 1 – 5 PM.

An electronic copy of this form is located at www.templeofpoi.com/events/safetysheet.html.