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20120270 Permit Pkg 09102012City of Yelm Community Development Department Building Division Phone: (360) 458-8407 Fax: (360) 458-3144 Applicant: Name: ENTERTAINMENT FIREWORKS Address: P.O. BOX 7160 OLYMPIA WA 98597 Property Information: Site Address: 1315 YELM AVE W Permit No.: 201 20270 Issue Date: 9/1012012 (Work must be completed within 180 days) Phone: 360 -352 -8911 Owner: YELM HIGH SCHOOL Assessor Parcel No.: 21724210500 Subdivision: N/A Lot: N/A Contractor Information: Name: ENTERTAINMENT FIREWORKS Address: P.O. BOX 7160 OLYMPIA WA 98597 Contractor License No.: Phone: Expires: 0 /00/0000 Project Information: Project: FIRE WORKS Description of Work: DISPLAY FIREWORKS FOR HOMECOMING. SEPT 21, 2012 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item FIRE Contractor ENTERTAINMENT FIREWORKS TOTAL FEES: Applic nt's Affidavit: I cert i that I have read and examined the information contained within the application and know the same to be t ue and correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm r gulations including those governing zoning and land subdivision, and in addition, all covenants, easem nts aq restr ions of re c In If applying as a contractor, I further certify that I am currently reciste din Lbe Stat of Washi t Fees $ 0.00 $ 0.00 OFFICIAL USE ONLY # Sets of Prints:_ Final Inspection: Date: Finn /� U I By. ,T Jr�o .217D CITY OF YELM COMMERCIAL BUILDING PERMIT APPLICATION FORM Project Address: 1315 Yehi Ave West, Yelm Parcel #: 21724210500 SEP 1 0 2012 Zoning; Current Use: Proposed Use: ❑ New Construction ❑ Re -Model / Re -Roof / Tenant Improvement ❑ Plumbing ❑ Mechanical ❑ Fire Prevent/Suppress /Alarm 13 Other Project Description /Scope of Work: Display Fireworks for Homecoming Project Value: Building Area (sq. ft) Parking Garage 1s' Floor 2nd Floor 3rd Floor Building Height Are there any environmentally sensitive areas located on the parcel? — completed environmental checklist must accompany permit application. If yes, a EitJtl[7fF1 .QINNER IENANTNAA?E: Yelm High School ADDRESS 1315 Yelm Ave W EMAIL CITY Y 1� m STATE__V&_ZIP 98597 TELEPHONE 3ho -45R- 6236 }1QHIlCT)Eh1%1NEER LICENSE # ADDRESS EMAIL CITY STATE ZIP TELEPHONE GENERAL-CONTRACTOREhtertairmalt Firewr ks, IA]ELEPHONE 360 - 352 -8911 ADDRESS PO Box 7160 EMAIL efi@py otech -rom CITY 01=pia STATE []A_ZIP 98507 FAX -160- 352 -0205 CONTRA'CTOR'S LICENSE # C -4085 EXP DATEl 1>l;ITY LICENSE # PLUMBI'NG.GONTRACTOR TELEPHONE ADDRESS EMAIL CITY STATE ZIP FAX CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE # MECHANICAL CONTRACTOR TELEPHONE ADDRESS EMAIL CITY STATE ZIP FAX CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE # Copy of City Mitigation documentation JFC). 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 Yalm. re Date / 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 (360) 458 -3835 PO Box 479 (360) 458 -3144 FAX Yelm, WA 98597 www.ei.ye1 n.wa.us ACORO� CERTIFICATE OF LIABILITY INSURANCE 5/22/20 02:20FV12 DD/YYYY) 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 endorsements . PRODUCER 6240 Britton-Gallagher Center Associates, Inc. 240 SOM Center Rd. Cleveland OH 44139 CONTACT NAME: PHONE FA% ac Not 4 AIC No. E-MAIL ADDRESS: INSURERSAFFORDING COVERAGE NAIC0 211512013 INSURER A:Lexonaton Insurance Co $1000000 PREMISES Ea INSURER B .Granite MED EXP Anya ) INSURED INSURER AX*SSUfpiUS IDS Company $1,000.000 Entertainment Fireworks, Inc. P. O- Box 7160 Olympia WA 98507 -7160 INSURER D: GENERAL AGGREGATE S 000000 GENL AGGREGATE UNIT APPLIES PER: 71 POLICY X T9i LOC PRODUCTS- COMP/OP AGG INSURER E: INSURER F: B AUTOMOBILE COVERAGES CERTIFICATE NUMBER: 1007496960 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. LTR TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 476 POLICY NUMBER POLM:Y EFF POLICY EXP LNM A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE KI OCCUR 1818833-04 2115=12 211512013 EACH OCCURRENCE $1000000 PREMISES Ea S50 000 MED EXP Anya ) S PERSONAL S ADV INJURY $1,000.000 GENERAL AGGREGATE S 000000 GENL AGGREGATE UNIT APPLIES PER: 71 POLICY X T9i LOC PRODUCTS- COMP/OP AGG f 000000 $ B AUTOMOBILE uAoLrTy ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS X ASWNED CA62858529 1512012 15/2013 Ee ecadem $1,000,000 BODILY INJURY(PSr Person) S BODILY INJURY (P..k Mp $ X �ROTV �AMAOE 5 i C UMBRELLA LIAR EXCESS LAB N OcCl1R CLNMSJAADE EAU705978 15/2012 1512013 I EACH OCCURRENCE S1,OOD,000 X AGGREGATE 51.000,000 DED I I RETENTION S 5 WORKERS COMPENSATION ANDEMPLOYERS'LABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? ❑ (Mantlamry In NH) M yea, 4 PI-18a UMF O DESCRIPTION OF OPERATIONS below N/A WCSTATU- 7M- TORY LIMITS E.L. EACH ACCIDENT S E.L DISEASE- EA EMPLOY $ EL DISEASE - POLICY LIMIT E DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ANaU, ACORD 101, AddNlonal Remarks ScheVule, N mae space Is re ul24) Date of Display: Sept. 21, 2012. 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. Gtk i ft-K A I t HULUEH CANCELLATION © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yelm High School Yelm Community Schools THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 476 Yelm WA 98597 AUTHOREEED�Dj� REPRESENTATIVE iYenab�v�'� © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Plow 2.0 Map Title m® APPLICATION STATE FAXROL FOR PUBLIC FIREWORKS DISPLAY PERMIT TO- Gnverninn hodv of city. town. or county in which disolav is to be conducted. DATE OF APPLICATION 9712 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 ADDRESS 5910 59th LP SE Lace WA 98513 LICENSE # P -4180 NAME OF ASSISTANTS: at least one required) NAME Andrew J Taisi is ADDRESS 4713 Parkside Dr SE, Lacey WA 98503 AGE 22 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Soccer Field North of Football Field @ Yelm HS @ 1315 Yelm Ave. Yelm WA DATE Friday September 21, 2012 TIME Halftime of football game NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED .75" Roman Candle Baton - 2 1.75" Aerial - 130 1.4G Class "C" Multi -shot Cake Devices - up to 100 ALL ITEM ARE CLASS "C" 1.4G ONLY THE ABOVE LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. MANNER & PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authors Delivered to site day of display. -----[STATURE OF PPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY Britton Gallagher & Associates • (Mark One) 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 One Cleveland Center, 30th Floor 1375 East "I" PERMIT PERMIT# L12097 DATE: 7nIZ 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: l c.-';�Asty"-- (F 11 nanlb of perso Inn, or corporation granted permit) RESTRICTIONS: /ill t Jv ! Ail A% i ryC Permit not valid without verification of ature of official granting pe i ) the appropriate State Fireworks License / 4 I (Tit e) LICENSE NUMBER: C -04085 C (Instructions on reverse side) 30001120 -050 (R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW (B): Permitee