20130189 Permit Pkg 05072013 o� �p City of Yelm Permit No.: 20130189
q'� � Community Development Department Issue Date: 5/07/2013
4 (Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
""`"'"°'°" Fax: (360)458-3144
Applicant:
Name: AMERICAN PROMOTIONAL EVENTS Phone: 253-922-0800
Address: PO BOX 1318
FLORENCE AL 35630
Property Information:
Site Address: 17100 SR 507 Owner: WALMART#3705
Assessor Parcel No.: 64303101001 Subdivision: Lot:
Contractor Information:
Name: AMERICAN PROMOTIONAL EVENTS Phone:
Address: GINA JIRAK
PO BOX 1318
FLORENCE AL 35630
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: FIRE WORKS
Description of Work: Fire works stand for Yelm Jesus Name Pentecostal
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
FIRE AMERICAN PROMOTIONAL EVENTS $ 30.00
TOTAL FEES: $ 30.00
ApplicanYs Affidavit: OFFICIAL USE ONLY
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 #Sets of Prints:
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 further certify that I am currently Final Inspection:
registered in the State of Washington.
Date:
Signature Date
By:
Firm
Cit� of welm
(�6 ) �5e-saoz
REC#o 00127045 5/0"l/2013 ;3:35 PM
OPER: CO TERM; 001
REF#: 30022861�
TRAN: 33.00U0 BUILDING PERMIT5
2��13�189 30.00CR
AMERICAN pROMOTIONAL EVENTS
17100 SR 507
FIRE 30.qOCR
TENDEREU: 30.00 CHECK
APPLIEp: 3�.00—
CHANGE: � 0.00
0
�
MAY 02, 2013
Gary Carlson
Building Dept.
City of Yelm
105 Yelm Avenue West
Yelm, WA 98597
Dear Gary Carlson,
Enclosed is a check for $30.00 and all applicable information to apply for 1
temporary retail fireworks stand permit for the upcoming 2013 July season.
If you have any questions, please feel free to contact me at (253) 922-0800,
thank you.
Sincerely,
;��� �
J��
Gina Jirak
Licensing & Permits
American Promotional Events, Inc. - Northwest
Enclosure(s)
AMERICAN PROMOTIONAL EVENTS, INC.
2120 MILWAUKEE WAY•TACOMA,WA 98421
TACOMA(253)922-0800•SEATTLE(253)838-1099
FAX(253)830-2930
www.tntfi reworks.com
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
WWT7150
TO: Governing body of city, town, or county in which DATE OF 03.13.13
fireworks stand will be located. APPLICATION:
Auplicant Name: Address, Citv, State:
YELM JESUS NAME 2120 MILWAUKEE WAY, TACOMA„ WA 98421
PENTECOSTAL
Sponsor (If other than applicant): Address, Citv,State:
GREG MATTOCKS 2120 MILWAUKEE WAY, TACOMA„ WA 98421
Location of proposed fireworks stand: [Enclose drawing of stand location]
17100 STATE RT 507 SE YELM, WA WALMART #3705
Manner and place of storage prior, during, and after sales dates:
ON SITE WITH SECURITY
State Licensed Fireworks Supplier:
American Promotional Events NW 2120 Milwaukee Way, Tacoma, WA 98421
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREW ORKS S TAND PERMIT
For The Fireworks Sales Year Of: 2013
(Must be conspicuously displayed at all times while the stand is open to the public)
By virtue of having been granted a license by the State of Washington and this permit from
CITY OF YELM the local governing authority, the named person, firm or organization is hereby
authorized to sell U.N. 0336 1.4G Consumer fireworks at the location designated herein between the
following date and times:
Sales For Julv 4th Sales For December 315t
From: _JC�.z���'�,� � , ,1 �:� �� /sl�'��-f'F,l From:
To: __�L� ��� S�,� c�i ?� �� �:��;�, To:
Sponsor: YELM JESUS NAME PENTECOSTAL
Location:f��1�l�ART #3705 17100 STATE RT 507 SE YELM WA
�S� / �y,� /s/ ��-(-� FOR GREG MATTOCKS
Signature of Official Granting Permit ignature of Applicant
/'�
�
Title: ,� � ir� ���� Agency: � (~ Gs; '--<-��
;
Date: t�'� ` � � '< Permit Number: ��L',1 �' � � �`�
Licensee Name: YELM JESUS NAME PENTECOSTAL License Number: 02382
30W-430.013 (Rev.3/OS)
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-°►�� CERTIFICATE OF LIABILITY INSURANCE,,,,,20,3 3/18/2013
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 endorsement(s).
PRODUCER p CONTACT
Lockton Com anies,LLC NAME:
3280 Peachtree Road NE,Suite 800 PHONE Fax
ac No eXc: ac No:
Atlanta GA 30305 E-MAIL
ADDRESS:
(404)460-3600
INSURER S AFFORDING COVERAGE NAIC#
�r,suReR a,:Scottsdale Insurance Com an 41297
INSURED INSURER B:
1359629 American Promotional Events,Inc.
DBA TNT Fireworks,IT10. INSURER C:
P.O.Box 1318 INSURER D:
451] Helton Drive wsuReR e:
Florence AL 35630
INSURER F:
COVERA CERTIFICATE NUMBER: 12255202 REVISION NUMBER: XXXXXXX
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.
INSR rypE OF INSURANCE ADDL SUBR pOLICY NUMBER MMIDDYIYYYY MMLDDY/YYYY LIM�TS
LTR INSR WVD
A GENERALLIABILITY Y N CPS1612503 ll/1/2012 11/1/2013 EACHOCCURRENCE
DAMAGETO RENTED
X MMERCIAL GENERAL IABILITY PREMISES(Ea occurrence) $ IOO OOO
CLAIMS-MADE �OCCUR MED EXP An one erson $ 5 ���
PERSONALBADVINJURY S ],OOO�OOO
GENERAL AGGREGATE $ 2 OOO OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2 OOO OOO
POLICY jE� X LOC $
AUTOMOBILE LIABILITY NOT APPLICABLE (Ea accident) $ XXXXXXX
ANY AUTO BODILY INJURY(Per person) 8 XXXXXXX
ALL OWNED SCHEDULED BODILY INJURY Per accident $ XXXXXXX
AUTOS NON�-OWNED PROPERTY DAMAGE $ XXXXXXX
HIREDAUTOS AUTOS
$ }�}�XXXXX
UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX
EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX
DED RETENTION$ $ XXXXXXX
WORKERS COMPENSATION NOT APPLICABLE TORY LIMITS ER
AND EMPLOVERS'LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N�A E.L.EACH ACCIDENT $ XXXXXXX
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ XXXXXXX
If yes,describe under E.L.DISEASE-POLICY LIMIT $ }(}�'�'�'}(}(}{
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCAilONS/VEHICLES (Attach ACORD 107,Additional Remarks Schedule,if more space is required)
Located at Wal Mart#3705 17100 SR 507 SE Yelm,WA(WWT7150)Certificate holder is an additional insured on the General Liability as required by writien
contract subject to policy terms,conditions,and exclusions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
12255202 AUTHORIZED REPRESENTATIVE
City of Yelm
Yelm Jesus Name Pentecostal
PO Box 479 - ��'
Yelm WA 98597 `��} �
i
~ � �
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �OO 888- 10 CORD CORP TION.All rights reserved
Walmart �-���
Save money.Live bet
702 SW 8`" Street
Bentonville,AR 72716
Phone 479-273-4219
Fax 479-204-2283
Aprii.crawford(c�wa I-mart.com
January 1St, 2013
To Whom It May Concern,
American Promotional Events, Inc. dba TNT� Fireworks is an approved National
Supplier for 2013 to conduct fireworks sales on our stores' parking lots where this
type of promotion is legal. Events usually run 7 to 12 days with set up beginning
approximately 5 days prior to the event.
An American Promotional Events, Inc. dba TNT� Fireworks representative will call
you to introduce the company and discuss your participation in the event.
Participation is encouraged and does add additional income to your other income
account. The Store Manager must approve the store's participation and placement
on the parking lot by store stamping the Pre-Sale Survey. All stores have been
researched and approved by the Walmart Realty Department. TNT� Fireworks is
responsible for obtaining all necessary permits and/or licenses and must display
such permits and/or licenses at each location.
Thank you in advance for your cooperation in this matter and if you have any
questions, please contact Automated Consumer Services at (479) 273-4219.
Best Regards,
�
April Crawford
Manager Consumer Services
Walmart Stores, Inc.
SITE DIAG RAM
Date Drawn: March 17, 2008 Loc No: W��15o
Address: 17100 State Route 507 SE Ordinance of: City of Yelm
Parcel No:
Store/Center: Wal-Mart Superstore Tent Faces Direction of: Open To The North
Yelm Washington �i�j���
City & State: � Tent Size: 20 x 40
Cross Streets: Notes: DO NOT STAKE TENT � WATER BARRELS
• OR CEMENT �LOCKS ONLY
GPS Co-ordinates
. 46.56.003 N
1�2.37.725 W
Tire&Lube
Main Entrance Grocery
Garden Center Wal-Mart
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COL.OR ��ed
����.� Ape�c II C�agome
��TE �'RO��SS�� 1— I I°9 6
RE: Tent Securify, Flame Resistance and nearest telephone
➢ The cer�ificates of flame resisfance. There is one for the red material and one for
the whife material used in the tent. Each of the tents wili also have a tag attached
notir�g that it is flame resistant.
9 As for securi#y, when the tent is not open for business, there will be at least two
people at each tent throughout the night. THEY WILL NOT BE SLEEPING. They will
have a cell phone as well as an air horn to scare anyone who may attempt to break in.
These tents will also remain lit-up throughout fhe night. There will not be a fence
around the tent, but we do rope off 20ft. away from the tent ali the way around the with
brigh� colored pennants_
➢ N�arpst T'elephones are noted on each site diagram for the tents.
➢ The flloor plan goes for all 20x40 and 3C�t�0 tents.