20100186 Fireworks Permit 09302010City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Applicant:
Name: YELM SCHOOL DISTRICT
Address: P.O. BOX 416
YELM WA 98597
Property Information:
Site Address: 11418 VFI M AVF W
Assessor Parcel No.: 21724210500 Subdivision:
Contractor Information:
Name: ENTERTAINMENT FIREWORKS
Address:
P.O. BOX 7160
OLYMPIA WA 98597
Contractor License No.: Expires:
001051.0
Project Information:
Project: FIREWORKS
Permit No.: 20100186
Issue Date: 9130/2010
(Work must be completed within 180 days)
Phone: 458 -6128
Owner: YELM SCHOOL DISTRICT
Lot: N/A
Phone: 360 - 352 -8911
12/31 /2010
Description of Work: DISPLAY FIREWORKS FOR HOMECOMING HALFTIME OF FOOTBALL GAME FRIDAY,
OCTOBER 22, 2010
Sq. Ft. per floor: First
Second
Third
Garage
Basement
Fees:
Item
FIRE
Heat Type (Electric, Gas, Other):
Contractor
YELM SCHOOL DISTRICT
TOTAL FEES:
Applicant's Affidavit:
I certify that I hive read and examined the information contained within the application and know the same
to be true and Porre.ct. I also certify that the proposed structure is in conformity with all applicable City of
Yelm regulati s i uding those governing zoning and land subdivision, and in addition, all covenants,
easements an re ricti s of�record. If ppl. ing as a contractor, I further certify that I am currently
registered in t e S a Wa¢hin R-
t__L1�e4dCt•1,�..,. -
Signature / -Date -
Firm
Fees
$ 0.00
$ 0.00
OFFICIAL USE ONLY
S Sets of Prints:_
Final Inspection:
Date:
By:
Do ali® APPLICATION
PART I w.j.,A FOR PUBLIC FIREWORKS DISPLAY PERMIT
TO: Governing bodv of city, town. or countv in which disolav is to ha rnndurtad
DA TYAPPLICATION
sr�cr7
APPLICANT
NAME
Entertainment Fireworks, I
ADDRESS
c. PO Box 7160
Olympia WA 98507 -7160
PHONE
360 - 352 -8911
SPONSOR
Yelm High School
ADDRESS
1315 Yelm Ave.
Yelm WA 98597
PHONE
360 -458 -6236
PYROTECHNIC OPERATOR
NAME
Jacob Johnson
ADDRESS
11547 Morris RD
SE, Yelm WA 98587
LICENSE#
P -04313
NAME OF ASSISTANTS: at least one required
NAME
Casandra Johnson
ADDRESS
11547 Morris RD
SE, Yelm WA 98587
AGE
21
NAME
ADDRESS
AGE
EXACT LOCATION OF PROPOSED DISPLAY
LOCATION
Soccer field north of football field @ Yelm
HS @ 1315 Yelm Ave, Yelm WA
DATE
Friday October 22, 2010
I TIME
Halftime of football game
NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED
.75" Roman Candle Batons - 2, 1.75" Aerial
- 120,
1.4G Class "C" Multi -shot Cake Devices - up
to 100
ALL ITFMS ARE CLASS "C" 1.4G
ONLY THE ABOVE LISTED PRODUCT DESCRIPTIONS ARE AUTHORIZED FOR THIS DISPLAY
MANNER & PLACE OF STORAGE PRIOR TO DISPLAY
Subject to approval of Local Fire Authority)
Delivered to site day of display.
SIGNATURE OF APPLICANT
FINANCIAL RESPONSIBILITY
BONDING OR INSURANCE COMPANY
Britton Gallagher & Associates
(Mark One)
9:1 Bond or certificate of insurance attached
❑ Bond or certificate of insurance on file with State Fire Marshal
Bond or certificate of insurance shall provide minimum coverage of
$50,000/$1,000,000 bodily injury liability for each person and event,
respectively, and $25,000 property damage
ADDRESS
6240 SOM Center Rd. Cleveland OH 44139
'J PERMIT
PERMIT #ipQ gC,p DATE:
In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a
fireworks display as per the above application.
NAME:
RESTRICTIONS:
, .IOC]
name of person, firm, or
Permit not valid without verification of
the appropriate State Fireworks License
LICENSE NUMBER: C -04085
(Instructions on reverse side)
SFP 2 8 2010
3000 -020 -050 (R 02/05) Distribution: WHITE (A): Local Fire AuthorityPVEL-LOW18". ertnitee
201ow8 ID
CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: 1315 Yelm Ave West, Yelm Parcel #: 21724210500
Zoning; Current Use: Proposed Use:
❑ New Construction ❑ Re -Model / Re -Roof / Tenant Improvement
❑ Plumbing ❑ Mechanical ❑ Fire Prevent/Suppress/Alann ❑ Other
Project Description /Scope of Work: Display Fireowrks for Homecoming
Project Value:
Building Area (sq. ft) Parking Garage 13t Floor 2nd Floor 3'd Floor
Building Height
Are there any environmentally sensitive areas located on the parcel? If yes, a
completed environmental checklist must accompany permit application.
-I I96 ii I ^uy7i vq �p �� 1 �m�i Vt.
Yelm High • ••
ADDRESS 13 1 S YP I rn G
LICENSE #
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
°F ' -im TELEPHONE 360 -352 -8911
ADDRESS PO Box 7160 EMAIL afi(ap4Zrntorh. nm
CITY O.l)moia STATE WA ZIP 98507 FAX - -
CONTRACTOR'S LICENSE # C -04085 EXP DAT ]CITY LICENSE # 01�/• !J
TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
TELEPHONE
ADDRESS EMAIL
CITY STATE ZIP FAX
CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE #
Copy of City Mitigation documentation (TFC).
I hereby certify that the above Information Is correct and that the construction on, and the occupancy and the use of the
above described property will be In accordance with the laws, rules and regulations of the State of Washington and the
City of Yelm.
,7 ,,,,,o �`A „o � ,dry,. ,
Applicant' lure Date
Owne Contractor Owner's Agent/ Contractor's Agent/ Tenant (Please circle one.)
All permits are non - transferable and will expire if work authorized by such permit is not begun
within 180 days of issuance, or if work is suspended or abandoned for a period of 180 days
105 Yelm Avenue West
PO Box 479
Yelm, WA 98597
(360) 458 -3 g g
wwm.ci 8-3 e.us IILIIII1111'IJJIIJIIIIIIII
SEP 2 8 2010
BY-- -------------- - - - - --
A`0/ZO CERTIFICATE OF LIABILITY INSURANCE
9;zi2a 0
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 endomement(s).
PRODUCER
Britton- Gallagher and Associates, Inc.
6240 SON Center Rd.
Cleveland OR 44139
CONTAM
NAME: NAME.
AMC No Eal: - - AN: M0440-544-12-44
ADDRESS:
PRODUCER
CUSTOMERI
INSURE 8 AFFORDING COVERAGE
NAIC9
2/15/2011
INSURED
Entertainment Fireworks, Inc.
P. O. Box 7160
INSURERA: Lexington Insurance Co
PREMISES
INSURERG:Granite State Insurance Co.
23809
INSURERC:AXiS Surplus Ins Company
Olympia WA 98507 -7160
INSURER D:
INSURER E:
8
PERSONALS ADV INJURY
INSURER F:
OOVtIVAUtS CERTIFICATE NUMBER: 77047.11A An 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.
INS
TYPE OF INSURANCE
POLICY NUMBER
MMmDYEFF
MPµLICYEXP
LIMITS
A
GENERAL LIABILITY
1619933 -02
2/15/2010
2/15/2011
EACH OCCURRENCE
81,000,000
PREMISES
$50,000
X COMMERCIAL GENERAL UABILITY
CLAIMS-MADE 1XI OCCUR
MED EXP (Any one )
8
PERSONALS ADV INJURY
81,000,000
GENERAL AGGREGATE
s2,000,000
GENL AGGREGATE
POLICY
UNIT APPLIES PER
X PRG" LOC
MrT
PRODUCTS - COMP)OP AGG
82,000,000
8
B
AUTOMOBILE
LABILITY
ANY AUTO
CA62658527
2/15/2010
2/15/2011
COMBINED SINGLE LIMIT
(Ea soddMR)
81,000,000
X
BODILY INJURY(Perpalaon)
S
ALL OWNED AUTOS
BODILY INJURY (Par attoNRd)
8
SCHEDULED AUTOS
X
PROPERTY DAMAGE
(Par acddanq
8
HIRED AUTOS
X
8
NON-OWNED AUTOS
3
C
UMBRELLA UAB
X
OCCUR
FAU705978
2/15/2010
2/15/2011
EACH OCCURRENCE
81,000,000
X
AGGREGATE
81,000,000
EXCE88 LAB
CLAIMS -MADE
DEDUCTIBLE
$
RETENTION E
WORKERS COMPENSATION
AND EMPLOYERS' LABILITY
MyPROPRIETORIPARTNER,FXECUTIVE YIN
OFFICERIMEMBER EXCLUDED?
(Mandatory b Wd
n yea, daaa,ee weer
DESCRIPTION OF OPERATIONS below
NIA
WC STATU- OTM-
E.L EACH ACCIDENT
8
E.L DISEASE - EA EMPLOYE
8
E.L. DISEASE - POLICY UNIT
s
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES tRUnh ACORD 101, Additional Ramaros Sd addle. It Tole apse N required)
Date of Display: October 22, 2010. Location: Soccer Field next to Football Field in Fenced Area. Addl.
Insureds: Yelm High School; Yelm Community Schools; Yelm Fire Dept.; their officers, agents, and
employees when acting in their official capacity as such.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
Yelm High School Yelm Community Schools IN ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 476
Yelm WA 98597 AUTHORIZED REPRESENTATIVE
ACORD CORPORATION. All rights reserved.
..wnu am t<w ) 1 ne ALVttU name and logo are registered marks of ACORD
CITY OF YELM
2010
CLERK TREASURER'S OFFICE
KENNETH E. JULIAN
TO OPERATE
ENTERTAINMENT FIREWORKS, INC.
PO BOX 7160
OLYMPIA, WA 98507-7160
TYPE OF LICENSE
SERVICES (OUT OF TOWN)
2010
LICENSING PERIOD JAN, 1, 20 10
OR FROM TO DEC. 31, 20 10
LICENSE NUMBER
25. 00
(I "Ill-
.7.
PAID
APPLICANT'S RECEIPT
Washington State Patrol
o Fire Protection Bureau
Office Of The State Fire Marshal
a Washineton State Fireworks License
Pyrotechnic Operator: Jacob B. Johnson
Licensee Location: 11547 Morris Road Southeast
Ychn, WA 98597
Phone Number: (253) 244 -0997
Date of Issue
May 4, 2010
3000.420 -012 (A 9105)
0
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a
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3
Expiration Date
January 31, 2011
11575
0
a
tnr l .irPneP
Detach this wallet card and carry with you for
verification of certification.
Washtagtan state Patrol 1157 5
Fire Protection Bureau
Office Of The State Fire Marshal
Pyrotechnic Operator Jacob B. Johnson
License Number License Number: P-04313
Tyne of License: Pyrotechnic Operator
P -04313 Expiration Date: January 31, 2011
State Fie Martial Sigaaiae Ltoensce Signature
Ye/-'Aw fliyis/
as
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