20140167 Permit Pkg 05282014 ��OF TH�A� City of Yelm Permit No.: 20140167
'
� �� Community Development Department Issue Date: 5/28/2014
(Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
LM
MM�6NIMGT4w Fax: (360)458-3144
Applicant:
Name: AMERICAN PROMOTIONAL EVENTS NW Phone: 253-922-0800
Address: 2120 MILWAUKEE WAY
TACOMA WA 98421
Property Information:
Site Address: 17100 SR 507 SE Owner: WALMART
Assessor Parcel No.: 64303101000 Subdivision: N/A Lot: N/A
Contractor Information:
Name: AMERICAN PROMOTIONAL EVENTS NW Phone:
Address: YESENIA LAMM
2120 MILWAUKEE WAY
TACOMA WA 98421
Contractor License No.: Expires: 0/00/0000
Project Information:
Project: FIRE WORKS
Description of Work: WALMART FIREWORKS PERMIT
Fees:
Item Contractor Fees
FIRE AMERICAN PROMOTIONAL EVENTS NW $ 30.00
TOTAL FEES: $ 30.00
Applica Ys Affidavit: OFFICIAL USE ONLY
I certify at 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 re ulat ns� �ng those governing zoning and land subdivi ion,and in addition,all covenants,
easem nts restrict ns of record. If applying as a contractor, I fu her certify that I am currently Final Inspection:
register d in h tat of Washin n
Signatur Date Date:
Firm By�
Cit� af Y�lm
(36 ) 458-$402
REC#: 00161770 5/28/2014 11;08 AM
OPER: CO TERM: 001
REF#: 644931
TRAN; 33.0000 BUILOTNG PERMITS
20140167 30.00CR
AMERTCAN PROMOTIONAL EVENTS NU!
17100 SE STATE HWY 507
FIRE 30.00CR
TENDERED; 30.00 CHECK
APPLIEQ: 30.00-
CHANGE: 0.00
�,,.,,,,� FIRE PROTECTION BUREAU
�'IItEWORKS LICENSING PROGRAM
� PO Boa 42600
Olympia WA 98504-2600
�''w�+"''� (360}596-3914 FAX: (360)596-3934 e�
APPLICATION
F(?R RETAIL FTREWORKS STAND PERMIT
TO Governing body of city,town,or county in which DATE OF
fireworks stand will be located. APPLICATION 4/10/2 014
App1lCeIIt N8QICYELM NAME JESUS Address,City,State
PENETECOSTAL CHURCH 2120 MILWAUKEE WAY, TACOMA WA 98421
Sponsur(If other t6an applicaut) Address,City,State
GREG MATTOCKS 2120 MILWAUKEE WAY, TACOMA WA 98421
Location of proposed fireworks stand [Enclose drawing of staad location]
17100 SR 507 SE YELM WA WALMART#3705
Manner and place of storage prior,dnring,and after sales dates
In Stand With Security
State-Licensed Fireworks Supplier
AMERICAN PROMOTIONAL EVENTS 2120 MILWAUKEE WAY, TACOMA, WA 98421
- ------- -------- -- -- - -- -- - - - - ----- ---- -- - --- -- - ------ - ---- ---- -- - --
FI�:EWOR�KS STAND PE�IT
2014
For the Fireworks Sales Year of:
(Must be conspicuously displayed at a11 times while the stand is open to the public)
By virtue of having been granted a license by the State of Washi.ngton and this permit from
CITY oF YELM as the local governi.ng authority,the named person,firm or
organiza.tion is hereby authorized to sell U.N. 0336 1.4G Consumer fireworks at the location
designa.ted herein between the following date and times:
Sales for July 4�' Sales for December 313t
From: From:
To: To:
Sponsor
Location 171,0�._.eS�R 5 0 7 SE YELM WA WALMART#3 7 0 5
/g/ e,. �� �j�" FOR GREG MATTOCKS
Signature of Official Granting Permit Signature of Applicant
Title _��t� AgencY _.:f�� f�.r �f �1L2�.�.-�
Date L�' zzv�� Permit Number
YELM NAME JESUS
Licensee Name pENTECOSTAL CHURCH License Number 01235
3000-0ZO-pl3(R3/09)
0
2ayol(�7
May 13, 2014
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 2014 July season.
If you have any questions, please feel free to contact YESENIA LAMM at (253)
922-0800. Thank you for your time and attention to this matter, and allowing
our fundraisers in your wonderful city!
Sinc rely,
�f� I
Kerri McTigue
Licensing & Permits
American Promotional Events, Inc. - Northwest
Enclosure(s)
AMERICAN PROMOTIONAL EVENTS, �n,c. -�c�IVE�
S. 104 FREYA,WHITE BLDG. SUITE 120-B • SPOKANE,WA 99202
PHONE (509)536-6330 • FAX(509)536-6314 � MAY 2 0 2014
www.tntFireworks.com
� ao
� � � �
N �'w w° N � � � v °?
l� �IL a tD Z C'a, � � '
`— ^�,j �' r- (,Wj`� p ;� o
W � 3 o y .a � ° `n� �
� �; �t
� �'.ia . � � rR A Q ;� v c
U y � �G � � .�; �
� O � a ' ~ F � �� � �
y O
� U i +'� � �1 � ��U��ll� �..:.... V
O �p 0 �.. � � « Vl Z G��. N� � �
V � � O � C,� � � .v� � ��M F.
6) V�
'b •"„ra; ro �ioC � Q"'� 'J�..o�o � o
� � � �3 � C � F, 3 E �rn�ao � � �
� c
—,. � �h � � � o W�c�3 �� �
� � � � 3w � a �
� � � � �
'� T/1 �' c�a , 0 r.7 i o r� L
�r1 � � Q o .°'o � e �
� � [�, Z i E �•o, �
� " � z az , �
� i � Q' a°�i � a� Z w p(} ii.
y,� � , � N C � C d R ` � `e
+� u v v'�
O Z ..aUav� A .�7
.ry
I y
�
� y � �'
c . � �
^ �
O
��y v� ►•-i N
� N O N
O r.�.+ �i
C� w A �
� a �
� y
� � �
U
•I�1 i.i � ^� 'J
� '� .,.Sri N "��
� � �
_, ''�i Z W r' 4
c� �
� O a ° � �
� � � `� u � � w
ca y, '� A `� C�
� � � f y a o
•�y
C� C ''�'' [Z,� .�'., p
C v •� r� yV,� op ,J
O ;; � � � � ap r
a � � � U o � `�
a H � � �,
� � p '+.� � � o° � �
3w � V1 0 � d- ° o�o
� �.y c> bp o^ � O
� �
�; a� �
O `�"i �, a `� CV C7 �H CZ
� � � o�o o i� � �' � °
.q '��' � � � r�n �2 L7 ��y p x
��~y � '� � � � G7 � N
r+.l �"+ Z' � Q' � a 7 � 7 �' o,
� � � � � �° � z � z � �
� � � � � � � � o �
� ti � �i �, � a
c o � �
� � o o � o .s� +a
� a � � � V � � �
a � N H ri� �
DATE(MMIDD/YYYY)
ACORO� CERTIFICATE OF LIABILITY INSURANCE
`„� tl/1/2014 5/13/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVEIY 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 NAMEACT
3280 Peachtree Road NE,Suite#250 PHONE Feoc
NC No:
Atlanta GA 30305 e-nnai�
(404)460-3600 ADDRESS:
INSURE S AFFORDING COVERAGE NAIC#
iNSURER a:Everest Indemni Insurance Com an 10851
tNSURED American Promotional Events,IIlC. INSURER B:
1359629 DBA TNT Fireworks,Inc. �ruuReR c:
P.O.Box 1318 INSURER D:
45]1 Helton Drive
Florence AL 35630 INSURER E:
INSURER F:
COVERA CERTIFICATE NUMBER: 12934924 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.
�LTR TYPE OF INSURANCE �D SUBR pOLICY NUMBER MM�DY EFF MM DDY EXP UMITS
A X CoMMERCIALGENErtaILwBILRV y N $I$GL00242-1 3 1 Ii/1/2013 ll/1/2014 N
CLAIMSMADE �OCCUR PREM SES(Ea occTurrence) $ 3����
MED EXP M one rson
PERSONAL&ADV INJURY S 1,000�000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S O O
POLICY � ECT �LOC
PRODUCTS-COMP/OP AGG $ 2 O
OTHER: $
AUTOMOBILE LIABILITY NOT APPLICABLE (Ea accident) $
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident
AUTOS AUTOS $ XXXXXXX
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS qUTOS
$ ��XXXXX
UMBRELLA LIAB pCCUR NOT APPLICABLE EACH OCCURRENCE $ XXX���X�'
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION NOT APPLICABLE
AND EMPLOYERS'LIABILITY �,�N STATUTE ER
ANY PROPRIETOR/PARTNERIEXECUTIVE N�A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED�
(Nandatory in NH) E.L.DISEASE-EA EMPLOYE $ �{ '�X�'}�X
if yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ X�'X �'
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORO 707,Additlonal Remarka Sehedule,may be attached if more space is requfred)
PROPERTY LOCATED AT WALMART 17100 SR 507 SE YELM WA(WWT7150)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
12934924
YELM JESUS NAME PENTECOSTAL CHLJRCH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF YELM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX�49 ACCORDANCE WRH THE POLICY PROVISIONS.
YELM WA 98597
AUTNORIZED REPRESENT�7jV�.�� �
� /� � e
f�
�O 1988-20 ACORD CORPO ATION. All rights resenred.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
_ _
SITE DIAGRAM
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
City & State: Yelm, Washington ���� Tent Size: 20 x 40
Cross Streets: DO NOT S°fAKE TENT � WATER BARRELS
Notes:
' OR CEMENT BLOCKS ONLY
GPS Co-ordinates
46.56.003 N
12�.37.725 W
Tire&Lube
Main Entrance Grocery
Garden Center Wal-Mart �
Entrance
�
� iso�+
d �
i�, �o
c a
O =
._,
n;
m;
�; ��`�:;�,� '.:;,
c;
'�i o, �
c
;Y r
�
� a Cart Return
20 X 40 Tent
C
�
; a
Light House
1 �
40� �
E 63, �' � —A� � 30 _.a c
a
20 X 40 Tent Trellls
Brick Wall e
� W
'--°-°---°°-----°-----------------Grass--�-------------- Grass
Li ht Sidewalk °-----------°------------°-----°
" -°----°----------------°-°---;
9 `--�------°°°°--------------------- �----�---�--- Sidewalk
---__°_____--�-�-°_____---�-----°----_°°---�__-.-�----°___---°----------=
HWY 507
Open Field
Vti/�1137�r't :;�.
Waimart Services '°ZS'"�,ns�°`
Bentonville,AR 72718
Phone 479.277.04<2
Faz 479.273.8606
To: Walmart Management Team--Select Stores
From: Anthony Hyiton
Waimart Services
Sr. Director, Store Channel Operaaons a�d Execution
Date: 12/11/2013
Re: �ireworks prosuams on Walmart�aricina lots
This letter serves as autho�ization for American Promotional Events, Inc. dba TNT Fireworks to conduct
fireworks promo6on at your store during the time frame June 17''"through and induding July 8'",2014.7hey
a�e an approved supplier to conduct fireworks sales on our stores'parking lots where this type of promotion
is�egai. TNT�Fireworks is responsible for obtaining all necessary permits andlor licenses and must display
such permits and/or licenses at each iocation.Walmart grants permission for all patrons of the sale to utilize
the restroom faciiities at each participating store. If there are any concems, please do not hesitate to contact
me.
Store Actlon:
• The Store Manager to approve the store's participation and placement on the parking lot by
stamping the Pre-Sale Survey with a store stamp that has the store number and address imprinted
on i�The stamp will provide an acknowledgement that TNT�Fireworks has received approval to
I conduct the event in the parking Iot.
• TNT�Fireworks Customer Support Hotline at 1-800-243-1189
�Ye appreciate your support! Should you have any questions, please feel free to contact our team—we're
here to help.
Best Regards,
Anthvny Hyiton
Sr. Director,Store Channei OperaUons and Execution
Walmatt Seroi.�s.
Phone 479.204.2581
Anthonv.HvltonCc�nral-mart com