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2019.0420.FR001 Permit App - Yelm HS Homecoming 9-27-19THIS FORM IS INTENDED TO BE USED ASA GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING JURISDICTION AND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON WASHINGTON STATE PUBLIC FIREWORKS DISPLAY PERMIT Name of Event Yelm Hiqh School Homecom Street Address 131 W. Yelm Ave City Yelm Applicant County Thurston Event Date September 27, 2019 Event Time Half time approx 8:00 ❑ AM ® PM Applicant's/Sponsor's Name Yelm High School Phone No. (360) 458-8407 Pyrotechnic Operator Bradley Omon License No. P-04251 Experienced Assistant's Name Gary Schuette General Display Company Name Pyro Spectaculars North, Inc. Phone No. (509) 467-9252 Attach a separate piece of paper and/or copies of the following documents: • The number of set pieces, shells (specify single or multiple break), and other items. • The manner and place of storage of such fireworks prior to the display. • A diagram of the grounds on which the display is to be held showing the point at which the fireworks are to be discharged; the location of all buildings, highways, and other lines of communication; the lines behind which the audience will be restrained; and the location of all nearby trees, telegraph or telephone lines, or other overhead obstruction. • Documentary proof of procurement of Surety bond or public liability insurance. Authority Having Jurisdiction Name of Permitting Official Title Permit Granted: ❑ Yes Restrictions/Notations Signature of Permitting Officiaf Local Fire Code Authority Phone No. ❑ Yes, with Restrictions (see "Notations" below) ❑ No Date of Approval Permit Number If approved, this permit is granted for the date and time noted herein under the authority of the International Fire Code in accordance with Revised Code of Washington 70.77 and all applicable rules and ordinances pertaining to fireworks in this jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is responsible for any and all activities associated with the firing of this show. MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION 30001420-050 (R 3113) Please mail permit to: Pyro Spectaculars North, Inc. 4405 N. Evergreen Rd Spokane Valley, WA 99016 (509) 467-9282 Fax: (509) 467-3439 EVENT DATE: September 27, 2019 License Number: C-04239 SPONSOR/NAME OF EVENT. Yelm High School / Homecoming LOCATION OF DISPLAY: 1315 W. Yelm Ave, Yelm, WA 98597 MANNER & PLACE OF STORAGE PRIOR TO DISPLAY (Subject to approval of Local Fire Authority) Delivered to site day of display. ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. Type of Fireworks 11.2" Comets I 10.75" Multi -shot Cake Devices I 112" Multi -shot Cake Devices ]ALL ABOVE ITEMS ARE 1 AG CLASS "C" I Type of Fireworks SIGNATURE OF APPLICANT: - Office Administrator ACOR6, CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 9/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Britton Gallagher One Cleveland Center, Floor 30 1375 East 9th Street CONTACT NAME: PHONE FAX c e •216-658-7100 Arc No:216-658-7101 E-MAIL ADDRESS: INSURER(SLAFFORDING COVERAGE NAIC # Cleveland OH 44114 INSURER A :EV re J-ndemnity Insurance10851 _ INSURED INSURERB:M xum indemnity Company 6743 INSURER C: Pyro Spectaculars North, Inc. 5301 Lang Ave McClellan Park CA 95652 INSURER 0. INSURER E: INSURER F: DAMAGE TO RENTED PREMISES Ea occurrence $500,001) COVERAGES CERTIFICATE NUMBER: 229030784 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLiSUBR INSR i WVD POLICY NUMBER h POLICY EFF MMIDD POLICY EXP MMIDDIYYYY LIMITS A GENERAL LIABILITY S18GL00282-191 1/13/2019 1/13/2020 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $500,001) CLAIMS -MADE T1 OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,001) GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY I X PRO- LOC $ AUTOMOBILE LIABILITY COMBINrL),91NGL LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY €NJt1RY(Per accident) $ Y HIRED AUTOS NON -OWNED AUTOS I PROPERTY DAMAGE $ Per accident $ B UMBRELLA LIAB X OCCUR EXXC6017995 1/13/2019 1/13/2020 EACH OCCURRENCE $2,000,000 X EXCESS LIAR CLAIMS -MADE AGGREGATE $2,000,000 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N ANY PROPRIETORIPARTNERIE=XECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N I A WC STATU-OTH- UMLT,S ER E.L. EACH ACCIDENT $ 6L DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate Holder is named as an Additional Insured in regards to General Liability. Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Display Cate: September 27, 2019 Display Location: Yelm High School, Yelm WA See Attached... LCK I II - It A I t HUL IJhK Yelm High School 1315 W. Yelm Ave. Yelm WA 98597 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE p 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: AC"RZD� ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Britton Gallagher Pyro Spectaculars North, Inc. 5309 Lang Ave POLICY NUMBER McClellan Park CA 95652 CARRIER 2!!Lr EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Additional Insured: Yelm High School, Yelm School District, City of Yelm, S.E. Thurston County Fire Department, Yelm Fire Department and their officers, agents and employees when acting in their official capacity as such_ AC:UM) 1U1 (1UUB/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD u � •" Washington State Patrol Fire protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License ��bxxez°� Licensee Data Bradley R. Omon Phone Number: (360) 970.5524 P.O. Box 5753 Email Andress: brad—pyro8l@yahoo.com Lacey, WA 98509 Date of Issue: May 23, 2019 License Number: P-04251 Date of Expiration. January 31, 2020 Stake t=ire Marshal licensee Signature �R Licensee Wall Mount Gard Washington State Patrol Fire Protection Bureau i w 4 Office of the State Fire Marshal Pyrotechnic Operator License Licensee Data Bradley R. Omon Phone Number. (369) 970-5524 P.O. Box 5753 Email Address: brad—pyro8l@a yahoo.com Lacey, WA 98509 Date of Issue; May 23, 20'19 License Number. P-04261 ®ate of Expiration: January 31, 2020 state Fire Marshal Lice ee Signature General Display Employer Portion ;) Cut along dotted lines to release the four license card's_ 2) All fain license cards are individually legal and valid evidence of licensing_ 3) All toter cards constitcrte an entire license for a single operator. 4) The Licensee must sign all four pardons of the !!cense_ 5) ALL four license cards are legal and valid evidence of licensing, License Number; P-04259 6) The Licensee must carry either the wallet (landscape) or the lanyard card (portrait). Washington State Matra[ `Fire Protection Bureau License Number: P-04251 Pyrotechnic Cperator Pyrotechnic Operator License �� <� �; -; Licensing Type January 31. 2020 Washington State Patrol Current and valid until Fire Protection Bureau Bradley R. Ornon Pyrotechnic Operator January 31, 2020 Bradley R_ Oman CurrentNa[id kirttii Pyrotechnic Operator ✓ L ee sgnature State Fire M8rshal v State Fire hlarshai Licensee Data _ s. Pyro Spectaculars North, 5301 Lang Avenue McClellan, CA 95652 License 4Nu�iba, C-042 i D State Fire Marshal 3000-420-041 (10198) Washington State Patrol Fire l'ra��ect6 Buri Office of the State Fire Marshal General Display 'ro Ice Piro Spectaculars north, irtc 5301 Lang Avenue Y, McClellan, . A 95652 License Number: C-04239.'. eratio aal Date In State Agent: Richard :Vaughan Phone Nurziber, (509) 981-4186 mail Address esamoerio@pyrospec.com Date of lssue:Jaruary1'6, 2U 9 Date of xpira on:January 31, 2020 State l=ire Marshal Licensee S' ature 30f18 4204 f (70,78) 9ashing#®n State Patrol Fire Protection Bureau 1 � Office of the State Fire MarshalXx �? A General Digplay Fireworks Lac , as; Licensee Data rorratonal ©eta� -r Pyro Spectaculars North, In In StaEe Agent: RichardVaughan 5301 Lang Avenuery Phone dumber: (509) 9$1-418fi r x McClellan CA. 9.5652 i �{ Email Address csam o ros ec corn License Number. C 04239 fro {_ °erg�@ Y p Date of Issue -.January 16, 2019 k Date of Fxpiration.January 31 9020 tT. State Fire -Marshal Licensee i are 3000-420,041 (�G,7z7 , - .. '' 1Nas ington Stag PaUdI Fire Protection Btirea . Office of the State Fire Marshal mp rter<@ Works Liven Licensee Data Pyro Spectaculars North, inc 5301 Lenz; Avenue McCleilan, CA 95652° License umber: C-0423 ;. .., Date of Issue 16:', II State` Fire Marshal 300420-041 (10/18) �7Ytiti� N$p �A4SkK4+d4 Ope,:ationall Data: lr,State Agent:_ Riclhard Vaughan k Phone Number- (509) 981-4186 _ Email Address csamperio@pyrQspec,cern n. lit , T2'M at ' tEXpiration.-Januai� '� ' 2020 , 4 i-icensee f atUre ------------------------------- Washington State Patrol Fire -Protection Bu'- G2010eat' Office of the State Dire Marshal_ _ s Pyre Spectaculars € or h, Inc � � � In State Agent: Richard Vaughan 5301 rang Avenue Phone Number: (509)981-4186 McClellan, CA 95652s n�rnail Address.csam' uric@PYrospec cotes License Number C-04239:;��c� x Date of 1ssue:january.16,1 2019 g, Dale of'iairation.,anuary 3'l, 2020 State Fire Marshal Licensee` tore a000-azo-aar {ia)181 --------------------------------------- s-r Washington State Patrol Fire Protection Bureau Office of the re Marshal Importer Fireworks License Licensee Data.I Data' �'.. Pyro Spectaculars North, Ir}c f � �" � ;:iii State Agent;Richard Vaughan 530'1 Lang AvenueE F�llorie Number. (509) 981 -4186 McClellan, CA 95652- E mail Address: csamperio@pYrospec.com License [lumber: C-04239 Date of lssue:January 16, 2019 Rage of Ex State Fire Marsha! 300a -420-G41 001181 20108 � F• C = f C _ f +Jyc - STATE OF WA5KiNCION Profit Corporation BUSINESS LICENSE ti PYRO SPECTACULARS NORTH, INC_ 4405 N EVERGREEN RD E SPOKANE VALLEY, WA 99216-1277 UNEMPLOYMENT INSURANCE - ACTIVE TAX REGISTRATION - ACTIVE Unified Business ID #: 602810145 Business ID #: 001 Location: 0002 Expires: Mar 31, 2020 INDUSTRIAL INSURANCE - ACTIVE CITY ENDORSEMENTS: SPOKANE VALLEY GENERAL BUSINESS -ACTIVE PASCO GENERAL BUSINESS - NON-RESIDENT #28835 - ACTIVE LICENSING RESTRICTIONS: Not licensed to hire minors without a Minor Work Permit_ } REGISTERED TRADE NAMES- PYRO SPECTACULARS NORTH, INC. ,t. This documera lists the registrations, endorsements, and licenses authorized for the business named above. Sy accepting this document, the licensee certifies the information on the application } Was compleie, tree; and accurate Mine best of his or her knowledge, and that bijsiness :zil! be conducted in compliance with all applicable washingtuji state, county, and city regulations. Dimctar, tleuartmeut of Revenue r 0,4 STATE OF WASHINGTON BUSINESS LICENSING SERVICE Thank you for filing online Our processing time generally takes up to 10 business days. Some endorsements may take more time for state or city approval. You will receive your business license with approved endorsements in the mail. An updated business license will be mailed to you when additional endorsements are approved. Confirmation Number: 0-010-262-714 Filing Date and Time: 09/1 91201 9 02:58:59 PM Payment Method: Credit Card ending in 2269 There is a 2.5% credit card convenience fee charged by a third party vendor. Business Entity Information Entity Type: Corporation Name of Entity: PYRO SPECTACULARS NORTH, INC. UBI : 602-810-145 Business Location Information Firm Name: PYRO SPECTACULARS NORTH, INC. Phone Number: (909) 355-8120 Fax Number: None Location Address: 1315 W YELM AVE YELM WA 98597-9449 Mailing Address: PO BOX 2329 RIALTO CA 92377-2329 Governing Person GILFILLAN IAN SOUZ4 JAMES SAMPERIO CHERYL Endorsement(s) Applied For Begin End Count Foe Yelm General Business 09/19/2019 09/3012020 1 $35.00 Industrial Insurance 09/19/2019 1 $0.00 Unemployment Insurance 09/19/2019 1 $0.00 Tax Registration 09/19/2019 1 $0.00 $35.00 Fee Type Begin End Count Fee BLS Processing Fee 09119/2019 1 $19.00 $19.00 Third Party Credit Card Fee $1.35 Grand Total: $55.35 UL0004