Image (23)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 AT A CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY. IT IS NOT MEANT TO BE
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 jurisdiction has no permit form of their own, complete this permit application and submit it with the local AHJ portion of your
D.,t. u 1r; N nrtec St—il f inner to the iurisdiction in which you wish to run your CFRS facility.
WASHINGTON STATE
FIREWORKS RETAIL SALES PERMIT APPLICATION
Applicant Information ❑ New/First Time Applicant ❑ Previous Permit Holder
Name of Group, Organization, or Person (Last, First, Middle Initial) Issued the Fireworks Retailer License
Name of Permit Applicant (Last, First, Middle Initial)
Permit Applicant Mailing Address (Complete Including Street, City, State, and ZIP Code)
( )Phone Number E-Mail Address Local Business Number (if required)
CFRS Facility Information ❑ Stand ❑ Tent Other: Size:
Specify Square Feet/Dimensions
CFRS Facility Address (Complete Including Street, City, State, and ZIP Code)
Name of Property Owner or Authorized Representative ( ) Phone Number Parcel Number for Stand Location
Fireworks Supplier Information List all of the licensed fireworks wholesalers who will be supplying this stand product
Storage Information ❑ On Site ❑ Off Site:
Storage Address (Complete Including Street, City, State, and ZIP Code)
❑ Sales Structure ❑ Detached Building ❑ Truck/Trailer ❑ Other:
Specify
CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines:
❑ Application/Permit Fee ❑ Insurance Certificate ($1,000,000) ❑ Clean -Up Bond Fee (if applicable)
❑ Valid Washington State Fireworks Retailer License ❑ Property Owners Written Permission
❑ Detailed Site Plan ❑ Interior Plan (required for tents and "other" facilities)
I 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.
Sianature of Permit Applicant Printed Name of Permit Applicant Date of Signature
FIRE CODE AUTHORITY HAVING JURISDICTION ❑ APPROVED ❑ DENIED
Permit Number Approved By Date of Approval
SEE BACK OF THIS FORM FOR ANY RESTRICTIONS, CONDITIONS, OR NOTATIONS ON THIS PERMIT
Signature of Permitting Official Printed Name and Title 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 AT ANY TIME THE STAND IS IN OPERATION
3000-420-013 (R 1/18)