2. Division of Fire Prevention

   641 Plainsboro Road

   Plainsboro, NJ 08536

   Phone: 609-799-0909 ext. 1203

4. Fire Safety Permit Application
6. Date of Application:
   Date of Application:
7. Date of Proposed Activity:
   Date of Proposed Activity:
9. Location Where Activity will Occur:
11. Organization Name:
13. Applicant Name:
15. Address:
16. City:
18. State:
19. Zip Code:
21. Phone Number:
22. Fax Number:
23. Emergency Number:
25. Email Address*
27. The above named applicant hereby requests permission to conduct the following activity at the above indicated location:
29. Describe the Keeping, Storage, Sale, Handling, or Manufacturing Involved:
31. State Quantities for each category to be stored or used, and the method stored or used:
33. 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.
35. Electronic Signature:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field