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2021.0322.FW0005 WAS2132 Retail Permit Application
THIS FORM IS INTENDED FOR USE BY LOCAL AUTHORITIES HAVING JURISDICTION (AHJ) IN THE EVENT THEY DO NOT HAVE A PERMIT FORM SPECIFIC FOR RETAIL FIREWORKS SALES RTA CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY. ITIS NOT MEANT TO sE REQUIRED IN ADDITION TO OR IN LIEU OF ANY LOCAL PERMITTING FORM AND/OR PROCESS THAT MAY EXIST WITH THE LOCAL AHJ. Directions: Provided the local jurisdictiou has no permit form of their own, complete this permit application and submit it with the local AIIJ portion of your Retail Fireworks Stand License to the jurisdiction in which you wish to run your CFRS facility. WASHINGTON STATE City of Yelm WAS2132 FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New/First Time Applicant ❑X Previous Permit Halder Yelm Pentecostal Church Name of Group, Oranization, or Person (Last, First, Middle Initial, and Date of Birth) Issued the Fireworks Retailer License Greg MattocKas Name of Permit Applicant (Last, First, Middle Initial, and Date of Birth) -212!) Mftaukee Way - Tacoma Washington 99421 Permit Applicant Mailing Address (Complete Including Street,'City, State, and ZIP Code) ( 360) 561-2700 _ cmattocks@q_mail.com ( ) Phone Number II --II E= -Mail Address Local Business Number (if required) CFRS Facility Information !—I Stand © Tent Other: Size: 20 X 40 = 800 sq. ft. Specify Square FeeVDimensions Safeway #1619 - 1109 Yelm Ave East - Yelm Washington 98597 CFRS Facility Address (Complete Including Street, City, State, and ZIP Code) 99002034408 Safeway Inc. ( ) Name of Property Owner Phone Number Parcel Number for Stand Location Fireworks Supplier Information List all of the licensed fireworks wholesalers who will be supplying this stand product TNT FIREWORKS Storage Information ❑ On Site ❑X Off Site: At the tent with security Storage Address (Complete Including Street, City, State, and ZIP Code) Q sales Structure ❑ Detached Building ❑ Truck/Trailer ❑ Other: Specify CHECKLIST FOR SUBMISSION Check with the local AHJ far all applicable submission dates and deadlines: © Application/Permit Fee Insurance Certificate ($1,000,000) ❑ Ciean-Up Bond Fee (if applicable) ® Valid Washington State Fireworks Retailer License ❑X Property Owners Written Permission ® Detailed Site Plan ❑X interior Plan (required for tents and "other" facilities) hereby certify the information in this application is true and correct. I am aware of and agree to comply with all relevant 61412021__ Date of Signature THE FIREWORKS RETAILER LICENSE HOLDER (LICENSEE) SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEN! BOTH A VAILASLE FOR INSPECTION AT ANY TIME THE STAND IS IN OPERATION 3004+120.013 (R 1Ill 6)