20130238 Permit Pkg 06202013 � City of Yelm Permit No.: 20130238
,� Community Development Department Issue Date: 6/20/2013
'�' (Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
w" " FBX: (360)458-3144
Applicant:
Name: KEN KERSEY Phone: 253-208-8489
Address: PO BOX 1106
MCKENNA WA 98558
Property Information:
Site,4ddress: 10602 106TH AVE SE Owner: RICH CHRISTIANSON
Assessor Parcel No.: 64303400502 Subdivision: N/A Lot: N/A
Contractor Information:
Name: KEN KERSEY Phone:
Address: KEN KERSEY
PO BOX 1106
MCKENNA WA 98558
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: FIRE WORKS
Description of Work:
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
FIRE KEN KERSEY $ 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.
Signature ��'<��o���?,�J4 ��C�-� Date �p ��J ��� Date:
Firm BY'
Cit� of Yelm
(36 } 458-8402
REC#: 00131110 6/20/2013 11 :03 AM
OPER; CO 1'ERM: 001
REF#: MC
TRAN: 33.0000 BIJILDING PERMITS
20130238 30.00CR
KERSEY, KEN
106Q2 106TH AVE SE
FIRE 30,OOCR
TENDEREQ: 30.OU OTHER
APPLIED; 30.00-
CHANGE: 0.00
.,o,,F FIRE PROTECTION BUREAU
;��"�'` FIREWORKS LICENSING PROGRAM
� PO Box 42600 I■ ■ I■�.
`� Olympia WA 98504-2600 ( � I �i
�`��`�� (360)596-3914 FAX: (360)596-3934 ����
+esnx�.�° �
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
TO Governing body of city, town, or county in which DATE OF
fireworks stand will be located. APPLICATION � -.�t�%�
Applic t Name /R�t �� Address,City,State
tC' a•
�. �r�w�r " ,��'- ,� (�'� `' ,�,��� r.� 8-��
Sponsor(If other tha ap licant) Address,City,State
.�` ? ���
Location of proposed fireworks stand [Enclose drawing of stand location]
����' S�'��C' �� �� 7 -��' ~ � �1 �� ���T�7
Manner and place of storage prior,during,and after sales dates
y
r� � e �f�� 7�J r� �` �'`I,� � � � �7� '/-�
State-Licensed Fireworks Supplier
l��'jC i��C �V L�F��lil��-s� �� P� .�.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWOI�:KS STAND PE�IT
For the Fireworks Sales Year of: ����
� (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
�i p � � �_ as the local governing authority, the named person, firm or
organization is hereby au horized to sell U.N. 0336 1.4G Consumer fireworks at the location
designated herein between the following date and times:
Sales for July 4th Sales for December 315t
From: � ��� �� � ,,ZG'���j From:
To: ��t � � �j :2�� �� To:
Sponsor
LOC1t10(��—_r� ,S�/�e'� 11� �U � �� '"` yE',I�Ii�fHr ��v 11
.---� ' —�
�S� � �S�
Signature of Official Granting Permit Signature of Applicant�
Title � � ��� �
,�, , �-i 'I 1�, � � L-, Agency � � ���-tJ�--�
Date L Permit Number
Licensee Name License Number
3000-420-U13 (R J/091
, `
Wasliinugton State patrol _
Fire Frotection Bureau � 5 � 8 2
°��e°fThe S�te�e�a�hal Fireworks Stand License
hington �tate Fireworks License �
License is Non-Transferable and Yalid for Only One Stand
ormation
,n Kersey
3ox 1106 State Fire Marsh l Sig t
IA 98558 License Number: WSPFL-02065 . Detach this wallet c d with you for ..
verification o ce fication.
mation ; WasWngcon State Patrol - —
'erson: Kenneth Allen Kerse i ��otection Bureau � 5 � 8 2
Y , Office Of The State Fice Marshal
imber: (253) 208-0489 � ANNUAL FIREWORKS STAND LICENSE
'ounty: Thurston Date of Exnira�ion Date of Issue i L�censee: ` xe � ersey
�mber: 8N-07919 January 31,2014 Apri125, 2013 � Contact Person: K ` �,�sey
License Number: �
Stand Number: S ,� � ,� lid For One StandJ
Date of E�pir io ;J �
dX,,[ {� �j ' Location• ! ��� �
t1011: � ✓ !�t(� � �+ —� .��"' l ��`, i � : tand,Locano '` , IeEed icenseeJ;
[Stand Location To Be Completed By Licensee � `�� `
� � ,� ���� � _ ��� ` _" �
•012(R 9105) ; State Fire arsha . ture � ��ccnce.e:Signah�re
KEN KERSEY
(253)208-0489 PHONE (360)458-3686 FAX
LEASE AGREEMENT
This agreement made and entered into this, 10thday of June 2013 by and between Christensen's Home
Furnishing Company, hereinafter referred to as the LESSOR and Ken Kersey, hereinafter referred to as
LESSEE.
LESSOR, in consideration of the covenants and agreements hereafter made by LESSEE on the following
described real estate located at 16628 State Route 507 SE,Yelm WA. 98597 for the purpose of selling
and distributing fireworks for the period of June 26`h, 2013 through July 6th, 2013. LESSEE agrees to the
following:
1. To pay LESSOR a non-ref ndable rent on the described premises for the agreed period in the
sum of$ �QC����
2. LESSEE will operate his business on the leased premises in a lawful manner and in full
compliance with applicable laws and regulations. Any and/or all non-compliance issues with the
City, County and or State will the full legal responsibility of LESSEE.
3. LESSEE agrees to remove all trash, debris and equipment from LESSOR premises and leave
premises in the same condition as was prior to lease period. No holes in the blacktop.
4. LESSEE will provide a certificate of Insurance to LESSOR on or before June 15th, 2013 and will
name described premises and LESSOR as additional insured.
LESSEE is hereby granted right of first refusal at this location for the same purpose and period for the
next 3 years, following the expiration of this lease.
f � �
:�
� .�
LESSOR-AGENT/OWNER OF Christensen's Home Furnishings
�������
LESSEE-KEN KERSEY, KEN KERSEY FIREWORKS
�'��� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�. 06/01/2013
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 ALTERTHE COVERAGE AFFORDED BYTHE 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 certifcate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT MBIef118 Allefl
MCGRIFF,SEIBELS&WILLIAMS,INC. NAME: _
P.O.BOX 10265 �C,No.Ext): 800-476-2211 _ (��,No): _
Birmingham,AL 35202 E-MAIL mall@mcgriff.com
ADORESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER n:Admiral Insurance Company 24856
INSURED INSURER B:
Jake's Fireworks,Inc. — — --
1500 E 27th Terrace INSURER C:
Pittsburg,KS 66762
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:SE,12625M 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 BYTHE 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP � LIMITS
LTR � IN R WV POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A GENERAL LIABILITY CA00001643802 02/15/2013 02/15/2014 Ep,CH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED 100,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurtence $
CLAIMS-MADE � OCCUR MED EXP(Any one person) $
X Non-Owned Stand End't Included PERSONAL&ADV INJURY $ 1,000,000
-__ _
GENER,4L AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY PR� X LOC $
AU70MOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y�N TORY LIMITS ..ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N�A �-- �----���-"-"---��
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
� DESCRIPTION OF OPER,4TIONS below E.L.DISEASE-POLICY LIMIT $
$
$
$
$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Ariach ACORD 101,Additional Remarks Schedule,if more space is required)
Sales Location:16628 State Route 507 SE.,Yelm,WA 98597
City of Yelm and all its employees,Christensen's Furniture and all its employees,Rick Christensen;Ken Kersey; Yelm Christian Center
Term:Feb.15th,2013 through Aug.14th,2013
The Certificate Holder and the above listed are Additional Insureds with respects to General Liability policy as required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Ken Kersey AUTHORIZED REPRESENTATIVE '"'••
P.O.Box 1106 �
McKenna,WA 98558 � -�-�' k ��-��- � -
Page 1 of 1 O 1988-2010 ACORD CORPORATION. All rights reserved.
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