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2021.0326.FW0006 WAS2133 Retail Permit ApplicationTHIS 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 ATA CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY. ITIS NOT MEANT TO BE REQUIRED IN ADDITION TO OR 1N LIEU OF ANY LOCAL PERMITTING FORM AND/OR PROCESS THAT MAY EXIST WITH THE LOCAL AHJ. Directions, Provided the local jurisdiction has no permit form of their own, complete tlkis permit application and submit it with the local AHJ portion of your Retail Fireworks Stand License to the jurisdiction in which you wish to run your CFRS facility. WASHINGTON STATE City ofYelrn WAS2133 FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New/First Time Applicant ❑X Previous Permit Holder Yelm Pentecostal Church Name of Group, Oranization, or Person (Last, First, Middle Initial, and Date of Birth) Issued the Fireworks Retaller License Greg Mattocks Name of Permit Applicant (Last, First, Middle Initial, and Date of Birth) 2120 Milwaukee Way- Tacoma_Wachinatnn 43RA71 Permit Applicant Mailing Address (Complete Including Street, City, State, and ZIP Code) ( 360) _ 561-2700 gcmattocks@cjmaii.com ( ) Phone Number E -Mail Address Local Business Number (if required) CFRS Facility Information ❑ Stand © Tent Other: Size: 30 x SO = 1500 sq. ft. Specify Square Feet/Dimensions Wal-Mart 17100 State Rt. 507 East - Yelm Washington 98597 CFRS Facility Address (Complete Including Street, City, State, and ZIP Code) Wal-Mart Inc. { ) 6430310100] 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 Q On Site ❑off Site: At the tent with Security Storage Address (Complete Including Street, City, State, and ZIP Code) ❑X Sales Structure ❑ Detached Building ❑ TruckiTrailer ❑ Other: Specify CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines. ❑X Application/Permit Fee Q Insurance Certificate ($1,000,000) ❑ Clean -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) 1 hereby certify the information in this application is true and correct. I am aware of and agree to comply with all relevant provisions of law, rule, and any ordinance of the state of Washington and the city/county permitting this CFRS Facility. 6/4/2021 Date of Signature THE FIREWORKS RETAILER LICENSE HOLDER (LICENSEE) SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEM BOTH AVAILABLE FOR INSPECTION A T ANY TIME THE STAND IS IN OPERATION 3000.420-073 (R 11116)