20130221 Permit Pkg 05302013 �pF THF/e� City of Yelm Permit No.: 20130221
� �` Community Development Department Issue Date: 5/30/2013
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
L
""`"'""°" Fax: (360)458-3144
Applicant:
Name: AMERICAN PROMOTIONAL EVENTS NW Phone: 253-922-0800
Address: 2120 MILWAUKEE WAY
TACOMA WA 98421
Property Information:
Site,4ddress: 1109 YELM AVE E Owner: SAFEWAY-TCYFL
Assessor Parcel No.: 85810000100 Subdivision: N/A Lot: N/A
Contractor Information:
Name: AMERICAN PROMOTIONAL EVENTS NW Phone:
Address: GINA JIRAK
2120 MILWAUKEE WAY
TACOMA WA 98421
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: FIRE WORKS
Description of Work: FIREWORKS PERMIT FOR SAFEWAY PARKING LOT. TCYFL.
Sq. Ft. per floor: First Heat Type(Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
FIRE AMERICAN PROMOTIONAL EVENTS NW $ 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 tr e and correct. I also certify that the proposed structure is in conformity with all applicable City of #Sets of Prints:
Yelm r gulations including those governing zoning d land subdivision,and in addition,all covenants,
easem nts s �ctions of record. If ap ing as a ontractor, I further ce�tjfy that I am currently Final Inspection:
registe ed' the St e of Wa i gt n. ' 1
Signat e �y �at� Date:
Firm BY'
il '*,
� ,��.� ����,,�� � -�.��� �
� 1� ����
Git� of Y�lm
(36 ) 458-8402
REG#: 00128815 S/30/2013 3:1� PM
OPER: CO TERh1: 001
REF#: 30023157
TRAN: 33.0000 BUILOING PERMITS
?_C�130221 30.OOCR
AMERI�AN PROMOTIONAL EVENTS N4�
1109 YELM AVE E
FIRE 3(l.00L'R
TENDEREG: 30.00 CHECK
APPLIED: 30.00-�
CHANGE: � � O.OG
I
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_� � 2����-r
�,�
,
;
MAY 14, 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 tent 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,
��L�.��-- :.
i
Gina Jirak
jirakg @tntfireworks.com
Licensing & Permits
American Promotional Events, Inc. - Northwest
Enclosure(s)
i
,
AMERICAN PROMOTIONAL EVENTS, INC.
2120 MILWAUKEE WAY•TACOMA,WA 98421
TACOMA(253)922-0800•SEATTLE(253)838-1099
FAX(253)830-2930
www.tntf i reworks.co m
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APPLICATION
FOR RETAIL FIREWORKS STAND PERMTI'
WWT7105
TO: Governing body of city,town, or county in which DATE OF MAY 02,2013
fireworks stand will be located. APPLICATION:
Applicant Name: Address,Citv,State:
PRAIRIE SPIlZIT DELIVERANCE 2120 MILWAUKEE WAY,TACOMA„WA 98421
HOUSE OF PRAYER
Sponsor(If other than apalicant): Address,Citv,State:
BISHOP MICHAEL DOSS 2120 MII,WAUKEE WAY,TACOMA„ WA 98421
Location of urouosed fireworks stand: [Enclose drawing of stand location]
1109 YELM AVE YELM,WA SAFEWAY#1619
Manner and place of storaQe arior,during,and after sales dates:
ON SITE WITH SECURITY
State Licensed Fireworks Sauplier:
American Promotional Events NW 2120 Milwaukee Way,Tacoma,WA 98421
- - - - - - - - - - - - - - -- - - - - - - -- - - - - - - - - -- - - - - - - - - -- - - - - - -- - - - - - -- - - - - -- - -
FIREWQRKS STAND 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 4�' Sales For December 315�
From: J t�„c�p ��., Z�� ��j From:
To: -� �---� � S �2 � I � To:
Sponsor: PRAIRIE SPIRIT DELIVERANCE HOUSE OF PRAYER
Location: St�►]��V�A�#1619 1109 YELM AVE E YELM,WA
/s/ � /s/ FOR BISHOP MICHAEL DOSS
Signature o �cial�rant►ng Permit Signature of Applicant
Title: �t,,.,l��r y G���i � Agency:�� � C�
Date:� ' �� �j Permit Number:
/
Licensee Name: PRAIRIE SPIRIT DELIVERANCE HOUSE OF PRAYER License Number:02503
3000-42(1013(Rev.?pS)
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
WWT7105
TO: Governing body of city, town, or county in which DATE OF MAY 02, 2013
fireworks stand will be located. APPLICATION:
Applicant Name: Address, City, State:
TCYFL 2120 MILWAUKEE WAY, TACOMA„ WA 98421
Suonsor (If other than applicant): Address, City, State:
SHAWNA HAYES 2120 MILWAUKEE WAY, TACOMA„ WA 98421
Location of proposed fireworks stand: [Enclose drawing of stand location]
1109 YELM AVE YELM, WA SAFEWAY #1619
Manner and place of stora�e prior, during, and after sales dates:
ON SITE WITH SECURITY
State Licensed Fireworks Supplier:
American Promotional Events NW 2120 Milwaukee Way, Tacoma, WA 98421
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWORKS STAND 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 31st
.._--
From: �j�,,�� ,1�'; _ 'Z�� �� From:
To: ...��...1 �i S �L � t� To:
Sponsor: TCYFL
Location: AY #1619 1109 YELM AVE E YELM WA
lsl �-C lsl �.c���,�i� FOR SHAWNA HAYES
Signature o icial Granting Permit Signature of Applicant
� D ��� A enc C G '
Title:� �� g y: �
Date: � ! ) / Permit Number:
Licensee Name: TCYFL License Number: 01279
3000-430-013 (Rev.2/OS)
,a►co' CERTIFICATE OF LfABILITY INSURANCE DA7E(MMIDDIYYYY)
�' i l/1/2013 6/25/2013
THlS CERTlFICATE 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.
IMPORTANY: If the certlflcate hoider is an ADDITiONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditlons of the policy,certain pollcles may requlre an endorsement A statement on this certNicate does not confer rigMs to the
certlflcate hoider in Ileu ot such endorsement(s).
PRODUCER Lockton Companies,LLC NAMTACT
3280 Peachtree Road NE,Suite 800 PHCNE �uc No:
Atlanta GA 30305 E�MAIL
(404)460-3600 A°°REU: -._----- —
INSURE S AFFORDING COVERAC,E NAIC N
�"w�R^:Scottsd 1 Ins rance om an 41297
INSURED American Promotional Events,IIIC. INSURER B:
1359629 DBATNTF'veworks,Inc. a�suRerec:
P.O.BOX I3IH MSURERD:
4511 Helton Drive INSURER E:
Florence AL 35630
INSURER P:
COVERA CERTIFICATE NUMBER: 12340084 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. NOTYVITHSTANDING 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 AFFOR�ED 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.
��� TYPE OF INSURANCE ADD SUBR pOLICY NUMBER MMIDDY� MM/DDIYYYY UMITS
A GENERALLIABILITY Y N CPS1612503 il!I/2012 11/1/2013
DAMAGETO RENTED
MMERCIALGENE 81LITY PREMISES(Eaoccurrence) S ]OOOOO
CLAIMSMADE�OCCUR MED EXP An wte son S
PERSONAL&ADV INJURY S 1�OOO,OOO
GENERALAGGREGATE t 2 Q
GEN'L AGGREGATE LIMIT APPLIES PER: PROWCTS-COMP/OPAGG S OOO
POLICY jRa }{ LOC S
nuronnosi�upsiuTr NOT APPLICABLE
(Ea accideM) E
ANY AUTO BODILY INJURY(Per person) 5
ALL OYVNED SCHEDULED BODILY INJURY Per acddenl S C C
AUTOS AUTOS
HIREDAUTOS AON-�OWNED PROPERTYDAMAGE S XXXXXXX
5 XXXXXXX
UMBRELUI W16 ��R NOT APPL[CABLE EqCH OCCURRENCE E XXXXXXX
EXCESSLIAB CWMS-MADE AGGREGATE b XX X
DED RETENTION3 ;
WORKERS COMPENSATION NOT APPLICABLE -
AND EMPLOYERS'LIABtLITY Y�N TORY LIM�T ER
ANY PROPRIEfORlPARTNER/EXECUTIVE
OFFICERmAEMBER FJSCLUDED? N/A E.L.EACH ACCIDENT 5
(MandeMry in NH) E.L.DISEASE-EA EMPLOYEE E XXXXXXX
Ifye s,Uescribe under
DESCRIPTION OF OPERATIONS 6elow E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATION5/LOCATIONS/VEHICLES�Athch ACORD 101,AddWonal Remarks Schadule,q more space Ia roqulrad)
'IHIS CERTIFICA'IE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFTCATES FOR THIS HOLDER,APPLICABLE TO TF�CARRtERS USTED AND 7F�POLICY 7ERM(S)REFERENCED
Located at Safeway 1109 Yelm Ave E,Yelm,WA(WWT7105)Certificate holder is an additional insured on[he General Liability as required by written 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 8E DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
12340084 AUTHORIZFD REPRESENTATIVE
City of Yelm
Prairie Sprit Deliverance House of Prayer
PO Box 479
Yelm WA 98597 � '
6i '
ACORD 25(2010105) The ACORD name end logo sre teglstered maACS of ACORD 0 86- 10 CORD CORP TION.All�Ights reserved
T�ID I�nlimited
' N T803 MarXet St Spol�a»e Wa 992�T 505��39-?809 Fax 509-467-�360
�
To Whom It Mav Concern:
TNT Fireworks, Inc. ha�been granted the exclusive rights to license, erect,a�d
maintain fireworks stands/tents on Safeway, Inc. store parldng areas for the
2oY3 fireworks season.
� � �\�1,��----
Van Phillips
December 20, 2012
�
�
�
Tc Who�a it rnav co�cern:
1'lease be acl��sed t,hat�ir. Van 1'hillips/1-VZp Ur�;irr�ited, �a.s a ��cez�se�o �o�duct
zireworks sales at the�a;Eeway store locafians listed o�t t�.e attached exhibit.
Safeway c.
�
By� � ---�---�
Its A :staz�t Vzce-�resid
By:
Its Assist e retary �
I2/20/2012
`ur� �vt�c�.� : ��
�
i�
EXHIBIT"A"
Location Location Name Address Line 1 City ST Year
WWB1550 SAFEWAY#1472 525 E COLLEGE WAY MOUNT VERNON WA 2013
WWB4750 SAFEWAY#545 6400 MERIDIAN MILTON WA 2013
WWH2156 SAFEWAY#534 3532 172ND NE ARLINGTON WA 2013
WWH2159 SAFEWAY 5802 134TH PL SE EVERETT WA 2013
WWH4250 SAFEWAY#494 152 ROOSEVELT AVE E ENUMCLAW WA 2013
WWH4552 SAFEWAY#459 20830- 108TH ST KENT WA 2013
WWH4701 SAFEWAY HWY 410 BONNEY LAKE WA 2013
WWH5751 SAFEWAY#362 938 N CALLOW BREMERTON WA 2013
WWH6352 SAFEWAY#639 110 E 3RD ST PORT ANGELES WA 2013
WWH6355 SAFEWAY#1922 2709 E HWY 101 PORT ANGELES WA 2013
WWM7105 SAFEWAY#1619 1109 YELM AVE E YELM WA 2013
WWT2155 SAFEWAY#535 20711 BOTHELL-EVERETT BOTHELL WA 2013
WWT2161 SAFEWAY#523 14826 HWY 99 N LYNNWOOD WA 2013
WWT2262 SAFEWAY#1522 20500 OLYMPIC PL ARLINGTON WA 2013
WWT2357 SAFEWAY 19651 HWY 2 MONROE WA 2013
WWT4059 SAFEWAY 13101 SE KENT KANGLEY RD KENT WA 2013
WWT4648 SAFEWAY#1798 11501 CANYON RD E PUYALLUP WA 2013
WWT4657 SAFEWAY#547 10105- 224TH ST GRAHAM WA 2013
WWT4662 SAFEWAY#1436 1624 72ND ST E TACOMA WA 2013
WWT4687 SAFEWAY(NEW) 13308 MERIDIAN E PUYALLUP WA 2013
WWT5250 SAFEWAY#541 4831 POINT FOSDICK DR NW GIG HARBOR WA 2013
WWT5754 SAFEWAY#1524 1401 NE MCWILLIAMS BREMERTON WA 2013
WWT6249 SEQUIM SAFEWAY 680 E WASHINGTON ST SEQUIM WA 2013
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COL.OR �•ed
S�'��.� Ape1t I I Ch gome
D��� p�Q������ I- 1 1�9 6
RE: Tent Security, Flame Resistance and nearest telephone
➢ T"he cer�ificates of flame resis�ance. Tliere is one for the re
d ma
the white material used in the tent. Each of the tents will also haveta tag attachedor
notir�g that it is flame resistant.
➢ As fur 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 all the way around the with
brigh� colored pennants.
➢ Near�st T'elephones are noted on each site diagram for the tents.
➢ The flloor plan goes for all 20x40 and 3Cx�0 tents.
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