20050307 Permit Pkg 09272005City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Applicant:
Name: Childs Fireworks
Address: P.O. Box 45637
Property Information:
Site Address: 1315 Yelm Ave. West
Assessor Parcel No. 21724210500
Contractor Information:
Name:
Address:
Contractor License No:
Subdivision:
Contact:
City:
Expires:
Project Information:
Project: YHS Home Coming
Description of Work: Fireworks display at Home Coming
License # C-04188
Sq. Ft. per floor: (1st) 0 (2nd) 0 (3rd) 0
Heat Type (Electric, Gas, Other):
Fees:
Item Item Fee Base Amt Unit Fee
TOTAL FEES: $0.00
Lot:
Phone:
State: Zip:
Business License:
Garage 0 Basement 0
Unit Rate No. Units Unit Desc
Applicant's Affadavit:
I certify that I have read and examined the information contained within the application and know the same
to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of
Yelm regulations including those governing zoning and land subdivision, and in addition, all covenants,
easements and restrictions of record. If applying as a contractor, I futher certify that I am currently
registered in the State of Washington. w -r
Signatu
Firm ~
Permit No: FIRE-05-0307-YL
Issue Date: 09/27/2005
(Work must be started within 180 days)
Receipt No:
Phone: 253-531-1658
City: Tacoma State: WA Zip 98445
Date _ ~~ ~ O ~~~
Sets of
i n a l I nsp~ect/ions:
Date: f //J/t.
/~~
By:
City of Yelm
Community Development Department
Building Division
Phone: (360) 458-8407
Fax: (360) 458-3144
Applicant:
Name: Childs Fireworks
Address: P.O. Box 45637
Property Information:
Site Address: 1315 Yelm Ave. West
Assessor Parcel No. 21724210500
Contractor Information:
Name:
Address:
Contractor License No:
Project Information:
Project: Yelm High School Home Coming
Description of Work: Aireal Fireworks Display
License #P-4019
Sq. Ft. per floor: (1st) 0 (2nd) 0
Heat Type (Electric, Gas, Other):
Fees:
City: Tacoma
Subdivision:
Contact:
City:
Expires:
(3rd) 0
Item Item Fee Base Amt
TOTAL FEES: 10.00
Applicant's Affadavit:
Permit No: SE-04-0162-YL
Issue Date: 10/07/2004
(Work must be started within 180 days)
Receipt No:
Phone: 253-531-1658
State: WA Zip 98445
Phone:
State: Zip:
Business License:
Garage 0 Basement 0
Lot:
Unit Fee Unit Rate No. Units Unit Desc
I certify that 1 have read and examined the information contained within the application and know the same
to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of
Yelm regulations including those governing zoning and land subdivision, and in addition, all covenants,
easements and restrictions of record. If applying as a contractor, I father certify that I am currently
registered in the State of Washington.
Signatu ~ Date ~Q ~ ~~ ~ /
Firm
# Sets of Prints:
Final Inspection:
Date:
By:
*************** -COMM. JOURNAL- ******************* DATE SEP-26-2005 ***** TIME 20:47 ********
MODE = MEMORY TRANSMISSION START=SEP-26 20:46 END=SEP-26 20:47
FILE No.=164
STN COMM. KEY NAME STATION NAME/EMAIL ADDRESS/TELEPHONE N0. PAGES DURATION
No.
001 OK s 912535311738 001/001 00:00:13
***** DP-3520 ********************** -Yelm CDD
-Yelm CDD -
- ***** - 360 458 3144- *********
Permit No: FIRE-05-0307-YL
Issue Date: 0912T(200b
(Work mull be stoned wlthln 180 days)
Receipt No:
Phone: 253531-0858
Stale: WA Zip 98dd5
Lot:
Phone:
State: Zip:
Btlalneaa License:
SQ. Ft. pertloor. (1st) 0 (2nd) 0 (3ro) 0 Garage 0 Basement o
Heal Type (Ebctrid, Gas, Other):
Feea:
Item Item Fae Base Aml Unll Fee Unll Rale No. Unlta Unh Desc
pment Department
7
Applicant
Name: Childs fireworks
Address: P.O. Box 46637 Chy: Tacoma
Property information:
Site Address: 1316 Yelm Ave. West
Assessor Parcel No. 21724210500 Subdivision:
Contractor Information:
Nome: Contact:
Address: City;
Controaor License No: Expires:
Project Irtfotmation:
Prgea: YH3 Home Coming
Descnptlon of Work: Fireworks dlaplay at Home Coming
LidonsE # C•04188
woe T City of Yelm
Community Develo
4
Building Division
Phone: (380)468.840
Fex:(3B0)458-3144
TOTAL FEES: E0.00
ApplicarrCa Affidavit
I Cenify that I nave read End azamined the Infontlatlon contained wNhln IhE appllcatbn and know the wme OFFICIAL USE ONLY
SO t>e true and GOAEU. I et90 CRfflty ihEt the pfOp06ed Btruaur0 is in Contonnity with EII BppiiCEble Gity Of ~ # S~tE ~ P~~.
YEIm fEgulallOn3 inUutling InOSE geVErning zoning and land SubdlVlaiOn, Intl in addition, all GOVenants,
easements and restriUions of record. Ii appying as a coniraUOr. I lulher ceniiy that I am cutrenty '
rogistered in the State of Washington. FNlal Inepecdan:
Dace-
Signelure Date -
-. BY•
~~~~
September 26, 2005
Mark/Rita
Thurston County Fire District, 2
Childs Fireworks came in Friday for a permit for home coming next Friday. See any
problems. Thanks
Gary Carlson
~ o o® APPLICATION
WRSHINGTON ST.TE fi1TROL FOR PUBLIC FIREWORKS DISPLAY PERMIT
~r
(Mark One)
® Bond or certificate of insurance attached
Bond or certificate of insurance on file with State Fire Mars
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
I U: c~overnmg posy of city, town or county In whlcn dlsplay Is to be conducted.
APPLICANT
NP,ME
~;rai ds' Fireworks
Isis- E~DDRESS
lay I'0
Box 45637 Tacoma, ~:~14 98445 PHONE
25j-»1-1658
SPONSOR ADDRESS PHONE
PYROTECHNIC OPERATO R
NAME ADDRESS LICENSE #
Bunn ~"iiL~s ~ 0 Box 45637 Tacoma, ',~;~`~ 98445 4019
NAMES OF ASSISTANTS: at least one re uire d
NAME ADDRESS
.,
Puyallup, Wx 98373 AGE
50
NAME ADDRESS AGE
LOCATION
1315 Yelm i:,ve. Yelm, u1x 98597 in the ~~11 fields West of the football fiel
DATE 9-30-05 TIME 7~ 00 t0 1 0~ 00 P M
270- 0.50 inch. Candles 162- 1.75 shells 10- 2.00 inch. salute 3- 1.50 inc
Candles 3- 2.00 inch. Candles 3- 2.00 inch Comets 35- Cakes 11 1.3G 24 1.4
BONDING OR INSURANCE CO.
COT~iBINED ~PECIl~LTILS INT' Z
ADDRESS
8362 Tamarack Village ~ 119
'vJoodbury, THIN 55125
~T II I PERMIT
PERMIT # ~~ _ b '± y3~7~ 1- L DATE: S'~d~~yl ~
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 Childs' Fireworks Zispla.y Co. , Inc.
(Full name of person, firm or corporation granted permit)
RESTRICTIONS:
Permit not valid without verification of
State General Display License
LICENSE NUMBER r-04188
DATE OF APPLICATION
9-22-05
\ Signature of Offical grant~l g..pefrnit)
(Title)
(Instructions on reverse side)
Distribtuion: WHITE (A): Local Fire Authority; YELLOW(B): State Fire Marshal's Office; PINK(C): Permitee 3000-420-050 (R 01/01)
~~ ~~ APPLICATION DATE OF APPLICATION
1RT I 5 ,R~i~ E PaROI ^ _ ^ 2 _ , r
!1~~!~ FOR PUBLIC FIREWORKS DISPLAY PERMIT `JA C J"/l
TOE Governing hndv of rity_ town or county in which disolav is to be conducted.
APPLICANT
NAME
~nilds' rireworks I';is DDRESS
lay ,'~;
Box 45637 ia:'oma, ,.!_z ac445 PHONE
255-53 i-165
SPONSOR
`Tei?i ;i ~h nl ADDRESS
1 YQ;
m ,rte Y ~ ',;. ~~~a PHONE
~ - - ~ ~
PYROTECHNIC OPERATOR
NAME
~~hn ,~, ~''hiicis ADDRESS
~ ~ Sox
45637 "'acoma ~-~ 9445 LICENSE #
401
NAMES OF ASSISTANTS: at least one re uired
NAME
D ~ , ~'.,i ADDRESS _ 37 3
~.r=t 7 ~~~+h '`+ •i(,ly!~illt~ ~ :'~i ~ ~v AGE 5
v
NAME ADDRESS AGE
EXACT LOCATION OF PROPOSED DISPLAY
LOCATION
v ~.., .~i V -- ~ r' Q ,~ ~ "~
1:15 _e - e. ~L.~~, ~ 7 _ _
i~ ~ f ~ ~a; 1' r Z f' l e t
ta.. ~~il _ i.,l~~is est ~~ ~h2 foot~al
DATE
-50-05 TIME
7:00 to 10:00 P '~
I E I P Y
270- 0.50 inch. "andles 162- 1.75 s"ells 10- 2.00 inch. salute 3- 1.5G ir.c
''~.r.:iles 3- 2.C0 incr. ~Gnales 3- _ 0~~ .nch "omets 35- akes 11 1.3," 24 1.4
MANNER & PLACE OF STORAGE PRIOR TO DISPLAY Sub'ect to a royal of Local Fire Authorit
SIG T O I i
FINANCIAL RESPONSIBILITY
BONDING OR INSURANCE CO.
~~~"~""~' ~ '-"~` :: i ~~ T ~ "~~ T ' (Mark One)
Bond or certificate of insurance attached
Bond or certificate of insurance on file with State Fire Marsha
ADDRESS
3 b2 T'am~ r2 C k V1 i i ~ ~ e r- 1 1 ~)
',~;oo dbu ry, T•1J 571 2 5 ~ Bond or certificate of insurance shall provide minimum
coverage of $50,000/51,000,000 bodily injury liability for each
person and event, respectively, and $25,000 property damage
ZTII PERMIT
PERMIT # l~~ _ b ~ v3~7- ~+ ~- DATE: y~d7~l,~ ~
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 "hills' Fireworks T~~is;,lay "o., Trc.
(Full name of person, firm or corporation granted permit)
RESTRICTIONS:
Permit not valid without verification of
State General Display License
LICENSE NUMBER ~-G4 i C~Ci
Signature of Offical
(Title)
Washington State Patrol 4 9 ~ 6
Fire Protection Bureau
Office Of The State Fire Marshal
Pyrotechnic Operator: John E. Childs
License Number: ' P-004,13'19
Type of License: Pyr ~~ niC Operator
Expiration Datie: Jan ~ , 31, 2006
Signature ~~~ Licensee
Washington State Patroi ~ ~ 2 5
Fire Protection Bureau
Office Of The State Fire Marshal
General Display: Childs Fireworks Display Compan
License Number: C-04188
Tyne of License: G~ne~Pi8play
Phone Number: (2~i} -1658
,..,.,.+,I.
S ~
Licensee;
Washington State Patrol ~ 9 2 6
Fire Protection Bureau
Office Of The State Fire Marshal
~~~~
S E P ~ 2 200
importer: Childs Fireworks Display Compan
License Number: C-04188
T~~pe of License: Itriport~er
Phone Number: (`253),31-1658
Yelm High School Product for Homecoming 2005
1.4GPyrotechnic
270 roman Candles for candle cannons
144 Singles, Doubles and Triples 1.75 shells
15 small cakes 125 to 300 grams (19 shot)
9 large cakes 500 grams (16 shot)
1.3G Pyrotechnic
12- 1.75 inch. Special Shells
6 - 1.75 inch. Salute Shells
10 - 2.00 inch Salute Shells
3- 1.50 inch. candles
3- 2.00 inch. candles
3- 2 inch comets
8- small cakes (25 shots)
3- large cakes (15, 30 or 50 shots)
~-_-=-_-_- _ - - -_ ---___ TCerti~ca~e=o~itsurar~ce_~'=~~~ ~=~~ ~' _~~ ~~-`~'~-~.
'_'._,
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_--_ --_-
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PRODUCER TIMS CERTIFICATE IS ISSUED AS A MATTER OF 01ATKTN ONLY AND
Corrminad SpeclaMle; IrllerrWOOnaI, hIC. CONFERS NO RIGHTS UPON THE CEfTTFK:ATE HOLDER THIS CERTIFCATE
8962 Tamarack VMepc GOES NOT AMEND, EXTEND OA LATER THE COVERAGE AFFORDED 8Y THE
Suite t 19 POLICIES BELOW.
Woodbury Mlntle•„eW 55125 INSURERS AFFORDNG COVERAGE
INSURER A: UMana-Yen, Lbyds d lwbon
INSURED INSURER B:
Chida FaaWOMe DiepL~y CO, Inc. INSURER C:
P.O. Bou< 15657
Tacoma WasNxglon 9W,5
COVERAGES
THIS lS TO CERTIFY THAT THE POLICIES OF BJSURANCE LISTED BELOW HAVE BEEN I53UED TO THE NAMED NVSURED ABOVE FOR TFIE PERIOD
INDICATED. NOTWITHSTANDBrG ANY REQUIREMENT, TERM OR CONORION OF ANY CONTAI-CT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED DA MAY pERTAM, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MEREW IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES NCLUDING. BUT NOT UNTIED TO THOSE FOIW WING= LMaRS SHOMIN MAY FIAVE BEEN REDUCED BY
PAID CLAIMS. ADDfTIDNAL CONDRIONS AND EXCLUSIONS: t) THE NSURANGE EVIDENCED BV THl$ CERTIFICATE IS UA8ILRY NSURANCE ONLY, R IS
NOT A BOND OR ANV FORM OF SURETY AGAINST WHICH SOMEONE OTHER AN 'INSURED' MAY ASSERT A CLAIM OR BRING ANY ACTION. SUBJECT TD
POLICY TERMS, CONDRIONS, DEFINITIONS AND EXCLUSIONS THE INSURANCE ONLY OVDEMNIF~S AN INSURED AGAINST CERTAOV Il:GAL LUIBILRY. 2)
THE INSURANCE DOES NOT COVER CLAMAS FOR BODILY IwURY OR PROPERTY DAMAGE OF THE NAMED NSURED'S SHOOTER(S) ASSISTANT(S) OR
ANY OTHER PERSON(S) INCLUDING ANY VOLUTE~$) PAATICIPATOVG IN ANY WAY 9r ANY DISPLAY OR SPECIAL EFFECT PERFORMED OR EXECUTEp
BY THE NAMED INSURED . 3K:OVERAGE DOES NOT APPLY TO CLAIMS FOR BODILY O~LAIRY Oli PROPERTY DAMAGE ARISING OUT OF THE INSUREDS
FAIUJRE TO FOLLOW NFPA ~) OTHER APPLICABLE REOUIREMENIS, LAWS OR RECOMh~ATIONS, MICLUDMG THOSE RELATING TO POST DLSPLAY
OR SPECIAL EFFECT SEARCHER OR CLEAN UP.
LT~R TYPE OF INSURANCE POLICY NUMBER ~~~ ~ ~~ LIMRS
A GENERAL LIABILRY 1 11 6370 6 1 61005 June 05, 2005 Junc 05, 2006 EACH ACCIDENT 55,000.000
CU11MS MADE MEDICJIL EJIP 55,000
fang ono psraon)
FIRE LEGAL LIABdITY .000
GENERAL AGGREGATE .000.000
PROOVCTS-COMPfOPS AGG 51,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE UMR g
!Fs eccidarn)
ANY AUTO eoDlLV IwuRY
ANY OWNED AUTD (Par Peen)
SCHEDUIJ=D aUTOs
HIRED ALTOS
BODILY gJ,IURY
MOH-{7WNED AUTOS ~ )
PROPERTY DAMAGE
fPcr .,on)
EXCESS LIABILRY EACH ACCIDENT
FOLLOWING FORM GREGpTE
WORKERS COMPENSATION STATU- OTHER
AND ORY UMRS
EMPLOYERS' LIABILITY
L EACH ACCK)EM
L DISEASE-EA EMPLOYER
E.L DISEAS~POLICY LIMR
OTHER
DESCRIPTION OF OPERATKXVS~LOCATIONSNEHICLESIDCCLUSIONS AppED 81' ENDORSEMENT/SPECWL PROVt510NS
Velm $chpel Dlthld and Cily of Yslm b employees Ana AdddppKd II~WOd a : rtrspedc Mw Seplwnber 30. 2005 Faaworka Drier b~ ba0 flptds w~l pt foelbyl /fold, 0!
t3t5 YNm Avonuo West YeYn. WA
CERTIFICATE HOLDER CANCELLATION
elm Scholl Dlslfid SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
101 1,•,1 Slrcol NoAII THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS W RITI'EN NOTICE TO THE
Ye1m, WA 98597 CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO
P
ON THE COMPANY, (T'S AGENTS OR REPRCSENTATIVES
OBLIGATION OR LIABILITY OF ANY KIND U
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A ITH AI7 F AT1VE `
!;HINDS FIREWORKS DISPLAY CO, INC,
P.O. BO>< 45631
?~ ~~ TACOMA, WA 96445
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