20130329 Permit Pkg 09132013 ''�/'as TH�p,��` City of Yelm Permit ►vo.: 20130329
Q�' ys
4 � Community Development Department Issue Date: 9/13/2013
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
YEL
"'°�"'"""" Fax: (360)458-3144
Applicant:
Name: YELM COMMUNITY SCHOOLS Phone: 360-458-1900
Address: P.O. BOX 476
YELM WA 98597
Property Information:
Site,4ddress: 1315 YELM AVE W Owner: YELM COMMUNITY
SCHOOLS
Assessor Parcel No.: 21724210500 Subdivision: N/A Lot: N/A
Contractor Information:
Name: YELM COMMUNITY SCHOOLS Phone:
Address: ERLING BIRKLAND
P.O. BOX 476
YELM WA 98597
Contractor�icense No.: Expires: 0/00/0000
Project Information:
Project: FIRE WORKS
Description of Work: DISPLAY FIREWORKS FOR HOMECOMING
Sq. Ft. per floor: First Heat Type (Electric, Gas, Other):
Second
Third
Garage
Basement
Fees:
Item Contractor Fees
FIRE YELM COMMUNITY SCHOOLS $ 0.00
TOTAL FEES: $ 0.00
ApplicanY Affidavit: OFFlCIAL USE ONLY
I certify tha I have read and examined the information contained within the application and know the same
to be true nd rre . Iso certify that the proposed structure is in conformity with all applicable City of #Sets of Prints:
Yelm regu ati ns clud g those governing zoning and land subdivision, and in addition, all covenants,
easement a d F s i ons of record. f applying s a contractor,I further certify that I am currently Final Inspection:
registered in t of W ,�sh"n o
� ' Date:
Signature $ Date
Firm By
�
G%'GVl�i�,�°��
CITY OF YELM
COMMERCIAL BUILDING PERMIT APPLICATION FORM
Project Address: 1315 Yelm Ave West, Yelm Parcel #: '7 4 10 00
Zoning; Current Use: Proposed Use:
❑ New Construction ❑ Re-Model/Re-Roof/Tenant Improvement
❑ Plumbing ❑ Mechanical ❑ Fire Prevent/Suppress/Alarm � Other
Project Description/Scope of Work: Display Fireworks for Homecominq
Project Value:
Building Area (sq.ft) Parking Garage 15� Floor 2°d Floor 3�d Floor
Building Height
Are there any environmentally sensitive areas located on the parcel? If yes, a
completed environmental checklist must accompany permit application.
BUILDING OWNER/TENANT NAME': Yelm High School
ADDRESS 1315 Yelm Ave W EMAIL
CITY Yelm STATEWA ZIP �f�5fi7 TELEPHONE �tin_4�R—Fl l n
ARCHITECT/ENGi'NEER LICENSE#
ADDRESS EMAIL
CITY STATE ZIP TELEPHONE
GENERAL CONTRACTORHh airxrxx,t F;rr-�,n�� T,-�ELEPHONE_360—�5�—R91 1
ADDRESS PO Box 7160 EMAIL efi(���o h. om
GiTY_Olvmt�ia STH i E wA ZiP �f3S�7 FAX 3�n_�57_n�C1,
CONTRACTOR'S LICENSE# C-04085 EXP DATE�-1 TY LICENSE#
PLUMBING 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(TFC).
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 Yelm.
Terri Schuette, Admin
Applicant's Signature Date
Owner/Contractor/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
I05 Yelm Avenue West (360)458-3835
PO Box 479 (360)458-3144 FAX
Yelm, WA 98597 www.ci.yelm.w¢.us
TMIS FORM IS lNTENDED TO BE USED AS A GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING
JURISDICTION AND PYROTECHNIC OPERATORS WITHIN TME STATE OF WASHINGTON
WASHINGTON STATE
PUBLIC FIREWORKS DISPLAY PERMIT
Applicant
Name of Event Yelm Migh School Momecor�ing
Street Address 1315 Yelm Ave. W,
City Yelm WA 98597 County Thurston
Event Date September 20, 2013 Event Time Halftime Approx 8:00 ❑ AM � PM
Applicant's/Sponsor's Name Yelm High School Phone No. (360) 458-6110
Pyrotechnic Operator Gary Schuette License No. P-04180
Experienced Assistant's Name Theresa Schuette
General Display Company Name Entertainment Fireworks, Inc. Phone No. (360) 352-8911
Atfiach a separate piece of paper and/or copies of the following documents:
• The number of set pieces, shells (specify single or multiple break), and other items.
• The manner and place of storage of such fireworks prior to the display.
• A diagram of the grounds on which the display is to be held showing the point at which the fireworks are to be
discharged; the location of all buildings, highways, and other lines of communication; the lines behind which the
audience wiil be restrained; and the location of ail nearby trees, telegraph or teiepnone lir7e�, or oti��er overnea�l
obstruction.
• Documentary proof of procurement of Surety bond or public liability insurance.
; Local Fire Code Authority
�---- - ------- ---_�_._----------- --------- -------------
Authority Having Jurisdiction � �
Name of Permitting Official G ��' ��
Title I�u� � Phone Na �00 ���g— �-{O�'
Permit Granted: �es Yes, with Restrictions (see "Notations" below) ❑ No
Restrictions/Notations
9 � 7�3 ��� �,�
Signa ure o Permitting Official D e o Approval Permit Number
If approved, rhis permit is granted for fhe date and time noted herein under the authority of the Internationa!Fire Code in
accordance with Revised Code of Washington 70.77 and all applicable rules and ordinances pertaining to fireworks in this
jurisdiction. This permit is INVAL/D unless in the possession of a properly licensed Pyrotechnic Operator, who is
responsible for any and all activities associated with the firing of this show.
MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION
3000-420-050(R 3l13)
Please mail permit to Entertainment Fireworks, Inc. �etta�h�
�
Post Office Box 7160 � �..
F
Otympia,WA 98507-7I60 � ��
(360)352-8911 Fax:(360)352-0205 �N�p�g�
EVENT DATE: September 20,2013 License Number:C-04085
SPONSOR/NAME OF EVENT: Yelm High School Homecoming
LOCATION OF DISPLAY: 1315 Yelm Ave.W,Yelm WA 98597
MANNER&PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Locai Fire Authority)
Delivered to site day of disptay.
ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THaS DISPLAY.
Type of Fireworks Quantity Type of Fireworks Qaantity
ALL ITEMS ARE CLASS"C" 1.4G
.75" 1.4G Class"C" Roman Candle Batons 2
1.75"Aerial Shells 100
1.4G Class"C" Multi-shot Cake Devices up to 100
SIGNATURE OF APPLICANT: `'
•������� �n����
.�,;�,.........�.,�.�.�. .� __:.�.�.._ ,��._ —
-- - -- _ --
� �-., --
� ACOR�� �ERTIFICATE OF L�ABILITY INSURANCE DATE(MMIDWYYYY)
8/5/2013
, � 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.
I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condiQans of the policy,certain poticies may require art endorsemerrt. A statement on this certificate does noY canfer rights to the
eertificate holder in lieu of such endorsement s.
PRODUCER
NAME:
I Britton Gallagher PHONE Fax
IOne Cleveland Center, Floor 30 c No -71 ac No: 1 -7 1
1375 East 9th Street ADDR�ESS: .
Cleveland OH 44114 INSURER S)AFFORDING COVERAGE NRIC#
i •
i n+suaeR n: n
INSURED INSURER B:Gf fl St In ura
Entertainment Fireworks, If1C. INSURERC:�(I ur I Ins �
! P. O. Box 7160
Olympia WA 98507-7160 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1837808511 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. N0TIMTHSTANDING 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 POIICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I INSR ADDI UBR —
L� TYPE OF INSURANCE ItJ MRID POLICY NUMBER ��DD EFF M LICY EXP V�TS
A GENERAL UABILt7Y 1619933-05 15/2013 15/2044 EACH OCCURRENCE $1,000,000
iX COMMERC�AL GENERAL LIABILITY PREM SES�Ea occu ence $50,000
CLAIMS-MADE �OCCUR MED EXP(Any one person) S
PERSONAL&ADV INJURY $1,000,000
GENERALAGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG $2,Q00,000
POLICY X PRO- LOC $
iB AUTOMOBILE LIABILITY CA626585210 15/2013 15/2014 Ea accident g1,000,000
X ANY AUTO BODtLY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per acadent) $
I � HIRED AUTOS X q�NOS�E� PROPERTY DAMAGE $
Per acddent
$
C UMBRELLA LIAB X OCCUR EAU705978 15/2013 15/2014 EqCH OCCURRENCE $1,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000
DED RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
IAMD EMPtOYER5 LIABILiTY� Y/N Y I
ANY PROPRIETOR/PARTNERIEXECUTIVE EL ERCHACCIDENT $
OFFICER/MEMBER EXCIUDED? � N��►
(Mantlatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCR►PTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Addkional Remarks Schedule,if more space is required)
Date of Display: Sept. 20,2013. 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.
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXRIRATWP1 DATE TMEREOF, NOTICE WlLL BE DEL{VERED IN
Yelm High School Ye4m Community Schools ACCORDANCE HIlITH THE P�UCY PROVISIONS.
PO Box 476
Yeim WA 98597 AUTHORIZED REPRESENTATIVE
���1�
O 1988-201U AGORD CORPORATION. AIt rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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Washington State Patrol �Q,6 9 2
Fire Protection Bureau
Office Of The State Fire Marshal
Washington State Fireworks License General Display License
General Display: Entertainment Fireworks-General Display
Post Office Box 7160
Olympia,WA 985077160 Detach this watlet cud and carry with you for
verification of certification.
In-State Renresentative: J. Larry Mattingly was�ington state ratrol qq
Fire Protection Bureau i 6�6 9 2
Phone Number: �3EO�S3f)-S3O9 Office Of The State Fire Marshal
General Disolav Ent�a�h Fireworks-Genera
LicenseNumber �f1'�8��'°�` `
Date of Issue Exuiration Date License Number � �
Tvpe of License e�I�� ;'
February 5,2013 January 31,2014 C-04085 Phone Number ���� ,€)��
; Exuiration Date: J��a�y �N j�i4
��
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3000-420-012(R 9/OS) State Fire ars �i ature Licensee Signature
Washington State Patrol 1 �6 9�
Fire Protection Bureau
Office Of The State Fire Marshal
Washington State Fireworks License Importer License
Imnorter: Entertainment Fireworks,Inc.
Post Office Box 7160
Olympia,WA 985077160 Detach this wallet cazd and carry with you for
verification of certification.
In-State Renresentative: J.La1ry Mlttingly Washington State Patrol
Fire Protection Bureau 1 4�9 0
Phone Number: �253� 53E)-5309 Office Of The State Fire Marshal
Imnorter E a� Fireworks,Inc.
Date of Issue Exniration Date License Number License Number �'�{�5���;°:;,
Tvpe of License ���t : "
February 5,2013 January 31,2014 C-04056 Phone Number 5���� _ re�
Exniration Date: J t�1 . �14
Y �
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3000-420-012(R 9lOS) � State Fire azs t�i ature Licensee Signamre
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Washington State Patrol 1 �6 91
Fire Protection Bureau
Office Of The State Fire Marshal
Washington State Fireworks License Wholesaler License
Wholesaler: Entertainment Fireworks,Inc.
Post Office Box 7160
Olympia,WA 985077160 Detach this wallet cazd and carry with you for
verification of certification.
In-State Representative: J.Larry Mattingly � Washington State Patrol
Fire Protection Bureau 14 S 91
Phone Number: (253)536-5309 OFfice Of The State Fire Marshal
Wholesaler Ente�"£��.h�rte Fireworks,Inc.
LicenseNumber C����`FS��"�T-.;";.,
Date of Issue Expiration Date License Number , ` r
TYae of License �Y,�t�a:�s$� ; �
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February 5,2013 January 31,2014 C-04056 Phone Number (�5���� ���
, Exuiration Date J il�'y�'`;�d�}f4
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3000-420-012(R 9/OS) �
State Fire ars �, i �ature Licensee Signature
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