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20130233 Permit Pkg 06182013 VOIDED �pF ZH�1� City of Yelm Permit No.: 20130233 � � Community Development Department Issue Date: 6/18/2013 (Work must be completed within 180 days) Building Division Phone: (360)458-8407 YEL "".""'"�'°" 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: 905 YELM AVE E Owner: RITEAID Assessor Parcel No.: 22730121200 Subdivision: Lot: Contractor Information: Name: AMERICAN PROMOTIONAL EVENTS NW Phone: Address: GINA JIRAK 2120 MILWAUKEE WAY TACOMA WA 98421 Contractor License No.: Exp s: 0/0 00 Project Information: Project: FIRE WORKS Description of Work: PRAIRIE SPIRI IN RITE ID P G LOT 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 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 Washi�gton� . Signatur :� ��1��—^C�-��''� `� Date � �d � Date: Firm � �_ BY: Cit� of Y�lm (36 ) 458-6402 REC#: OU1�0978 6/18/2013 3:37 PM UPER: CO TERM: t101 REF#. 30023308 �rl�Ary: 33.0000 BUILDI�NG P�RMITS 2f�130233 30.Of)CR AME�ICr�N PROMOTI�NAL EVENrS NW 9U5 YELM AVE E FIhE: 3Q.00CR �ENUERED: 30.00 CHECK APPLIED: 30.00- CHANUE; v� 0,00 ° ��j3 Q �Z 3� , June 05, 2013 Karen Bennett Community Development City of Yelm 105 Yelm Avenue West Yelm, WA 98597 Dear Karen Bennett, 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, ) f 1 �(�tt�-`_ � Gina Jirak jirakg @tntfireworks.com Licensing & Permits American Promotional Events, Inc. - Northwest Enclosure(s) AMERICAN PROMOTIONAL EVENTS, iNC. 2120 MILWAUKEE WAY•TACOMA,WA 9842'! TACOMA(253)922-0800•SEATTLE(253)838-1099 FAX(253)830-2930 www.tntfireworks.com APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWH7106 TO: Governing body of city, town, or county in which DATE OF MAY 30, 2013 fireworks stand will be located. APPLICATION: Applicant Name: Address, City, State: PRAIRIE SPIRIT 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Sponsor (If other than applicant): Address, Citv, State: BISHOP MICHAEL DOSS 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Location of proposed fireworks stand: [Enclose drawing of stand location] 905 E YELM AVE YELM, WA RITE AID Manner and place of stora�e prior, durin�, 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 4t'' Sales For December 315t From: U'K �z/� z�%. �Z,�/ � From: To: J�_1 y s z�� To: , • Sponsor: PRAIRIE SPIRIT Location: �t�ID 905 E YELM AVE YELM WA /s/ /s/ ' FOR BISHOP MICHAEL DOSS Signature of Official Granting Permit Signature of Applicant � �^� Title: �.��<��%�r��, �/l% Agency: ��i';� Date: Permit Number: Licensee Name: PRAIRIE SPIRIT License Number: 02503 3IX�-420-013(Rev.2J05) rn � cfl co � c� � o cYa w � � � � T/► O � z � h �d �..� �/1 �, �— r� � �, e°n � �.. c'd V � N � � 3 ... � ~/� � � �' � � �� + U �.�"+ RS � F�1 ,ti" � V � �� --.�.,_.CC C7 y Z .�? ..a •�y � ��.�g-��, a � L d � � � O � � � � � ' �� ,,�"ti�., a G y V� � � � "�j �, � 'O O .«+ .. p . � � � y CQ � '" v7 3� � � � � -- � � •O 0 y C/� � a� p tp��" �J o � C��' � � L�i � �� 1� �„ E� `'� � b � �Cz„� o a� � ,�,_ '�' 3 `� ;,a A" � � cJ Jc�:,� � � � � � N � e�a �p ��`��°�„r�.,;�`'� o\ /T� � �:L ' r3 f=+ a� �a a,��cn .� y on vv � _ C3.c c� '"' � "''a T��, � �'� � a � o � s � V1 N � w � � �Q � °�' ° `��' � T� � '�\ �L Z a �� a "�, :? �►_ VL � � \ � � �.' y �4 'Z, 7 W q p4 �� f "" Q a� � a� Z w o t} :: � � �1 J � � b a�+ C 'b � 'ir � � `a� � � � � � � q � p � � � u u co 0 z � � .-7U �..ari� A �] � � � � � � � v � U 'J ,.�� M � � � O �� M � � � O � O � cd � w A � -�r a � � � � � � '"'r �: w � i M� � � ° `�� V,`�1 � '^" ^ ° riy � W `Y' �Y � � � O � U � � � � � � � � Q, �" � � ." A �'' �, °' a �; � w i•r o �a � •••+ � o y � � �, � o O ,e V� � c�1 '� � �� M � � � F � � � � � �, � (/1 �� o0 � o � o0 w � U M s� O � O � � N .� z `i� O �N G� �.F-+ C/� � ^" � o � �r r�a 3-i rn t� 00 O C �� .� � � '.�".O' � � O � C� � p � ,.� � �"." � � Q 3-� (ZI � V � � o � �""� �'" r� � 4� r.+ -�-i Zi U � �.r-, v O � a�i � ~ c� H ��,, � � a o vs � �' �-+ „� � p � „� r, y '� p p � O .L ++ � � �� N � � v �"' `�' � a aNH � � DATE(MM/DDIYYYY) ACOR�� CERTIFICATE OF LIABILITY INSURANCE �,� lt/t/2ot3 6/18/2013 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 Lockton Companies,LLC NAMEACT 3280 Peachtree Road NE,Suite 800 PHONE Fax AIC No Ext: AIC No: Atlanta GA 30305 e-nnai� �4�4�46�-36�0 ADDRE55: INSURER S AFFORDING COVERAGE NAIC# �r,suaeR n:Scottsdale Insurance Com an 41297 INSURED American Promotional Events,IIIC. INSURER B: 1359629 DBA TNT Fireworks,IIIC. INSURER C: P.O.BOX 13�R WSURERD: 4511 Helton Drive INSURER E: Florence AL 35630 INSURER F: COVERA CERTIFICATE NUMBER: 12402944 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 7ypE OF INSURANCE ADDL SUBR pOLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD/YVYY MMIDDIYYYY A GENERALLIABILITY Y N CPS1612503 II/I/2012 11/I/2013 EACHOCCURRENCE DAMAGETO RENTED X MMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 1 OO OOO J CLAIMS-MADE �OCCUR MED EXP An one erson $ 5 �� PERSONAL&ADV INJURY $ ]�OOO,OOO GENERAL AGGREGATE $ 2 OOO OOO GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ ZOOOOOO POLICY ' PRO- ' JECT X LOC $ AUTOMOBILE LIABILITY NOT APPLICABLE (Ea accident) $ XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX ALL OWNED SCHEDULED BODILY INJURY Per accident $ XXXXXXX AUTOS AUTOS PROPERTY DAMAGE $ XXXXXXX NON-OWNED HIRED AUTOS AUTOS $ �'�'�'�'�'X�' UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE � XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE A - AND EMPLOYERS'LIABILITY ��N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ XXXXXXX OFFICER/MEMBER EXCLUDED? � N�A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ XX�{�{�'�'}{ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ XXXXXXX DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 107,Additlonal Remarks Schedule,if more space is required) Located at Rite Aid 905 E Yelm Ave,Yelm,WA(WWH7106)Certificate holder is an additional insured on the 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 CANCEILED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12402944 AUTHORI2ED REPRESENTATIVE City of Yelm Prairie Spirit PO Box 479 � Yelm WA 98597 `""� "`} f.� � I � �� . � �, � , � IACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD O 988- 10 CORD CORP TION.All rights reserved �w ��-ic�� C��c� �,- tj�\m �e- : .,✓ ��.\�n ,V��+ °1`��.�l� -- - � -��--.._.� -- --. - ,. �� \ �� ` \ - I , . ,. , I _ �,q, - �, - - s��c.� + , � - � - -� I - - --- --- .;.- - �_ I,,�,. v � �%�� U— '.� � ' � , . _ - �—� � i - --- ; � .__� `�� --. I ... . :_ .. �,�.,,�.-,�"��-�..-. �„ r _ F, � �_ �, �. ., � , � _ _ .� „ .= m _ � � .,. . _ _..,� .�..,..,_.�s�.z-.�..�._� _ _.,u � ,�..:,�.��,. , � �::�,��,�-_, , �'� _.�. _ _,: