Application for an

Explosives and Blasting Permit

Per Section 8-207.55, this application must be completed to demonstrate the applicant’s compliance with the regulations for conducting blasting operations within the City of Lawrence. Supporting documents will be required where indicated.

1) _____Document -Proof of Liability insurance coverage in the following minimums:

Commercial General Liability –                      General Aggregate $2,000,000

                                                                       Each Occurrence    $1,000,000

                                                                       Automobile Combined

                                                                                Single Limit      $1,000,000

                                                                        Worker’s Comp       Statutory Amt.

Insurance Company Name _______________________________

Insurance Company Contact Information ____________________

Expiration Date ________________________________________

Certificate of Liability Insurance provided to City Clerk ____/____

                                                                                        Yes   No

2) _____Document(s) -Copies of Explosive Blaster Permits, issued by the Kansas State

Fire Marshal’s Office, for all responsible persons on site.

3) _____Blasting Plan on file including the following:

Contractor Information:

Name of Contractor _____________________________________

Address ______________________________________________

Emergency Contact Number ______________________________

Business Contact Number ________________________________

                                Responsible On-site Personnel ________________________

                                                                                __________________________

                                                                                __________________________

                                                                                __________________________

Document – Scale drawing of project area which includes:

                                                ___Distances to all structures and facilities within 500 feet of the blast site,

                                                ___Type and amount of explosive materials ___________________________,

                                                                                                                      ___________________________,

                                                ___Distance from storage magazines to nearest structure (per Code) ________________,

                                                ___Proposed Seismograph locations during blasting,

___Designation of proposed preblast surveyed structures.

           4)___Document – Listing of all proposed preblast surveyed structures within 500 feet of the blast site,

           5)___Name and Address of independent Seismograph Monitoring firm _________________

                                                                                                                ______________________

                                                                                                                ______________________,

           6)___Document – List of addresses within 1500 feet of the blast site that have been

                                                Provided with written notification of blasting operations,

           7)___Document – Copy of the written notification posted which includes:

                                                                                Notice of intent to blast

                                                                                Name of Contractor

                                                                                Agency providing preblast surveys

                                                                                Insurance Company Name

                                                                                Insurance company claims process.

                Name of Applicant _____________________        Signature of Applicant__________________________

                Address of Applicant ____________________     Phone Number _______________________________

Lawrence-Douglas County Fire & Medical, 746 Kentucky Street, Lawrence, KS 66044  Phone: (785)832-7600