20140191 Permit Pkg 06162014 ��pF THEp�� City of Yelm Permit No.: 20140191
7
� '� Community Development Department Issue Date: 6/16/2014
d 'i+� (Work must be completed within 180 days)
Building Division
Phone: (360)458-8407
YELM
w�sw�ry4�Ow Fax: (360)458-3144
Applicant:
Name: KEN KERSEY Phone: 253-208-8489
Address: PO BOX 1106
MCKENNA WA 98558
Property Information:
site Address: 1405 YELM AVE E Owner: CHERYL SOJAK
Assessor Parcel No.: 22730140400 Subdivision: Lot:
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: FIREWORKS STAND
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 ONIY
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 StatQ of Washing on.
_ f � f � � Date:
Signature Date 1 /
By:
Firm
Cit� of V�lm
t3� � �5a-s4o�
REC#: 00163482 6/161201� 10:4d AM
pp��; �p TERM: 001
REF#: 1147
TRAN: �3.0000 8����I30,OOCRITS
20140191
KERSEY, KEN
1405 YELM RVE E30.00CR
FIRE
TENDERED: 30,00 CHECK
APPLIED: 30.00-
CHANGE: 0.00
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com�4eteci env�ronm�n�ai checkl�st mus9 pany perrr�st a�p��c8t�on
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w�thir� t80 d�ys of isauance,or if work#s auspende+�c�r a#�nd+ott�at!for a periati tsf t8tt t�aya
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��sf�f FIRE PROTECTION BUREAU
' FIREWORKS LICENSING PROGRAM
a�� PO Box 42600 ❑O ���
��" Olympia WA 98504-2600 W�SMINGTON 6TAlfi WRROL
�'"�+.:x.���F"`� (360)596-3914 FAX: (360)596-3934 �
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
TO Governing body of city,town, or county in which DATE OF
fireworks stand will be located. APPLICATION � -�- y
Applicant l�ame Address,City,State
��/1 /���'S-�° T; �%� c� � ���v `�t�i�l y ��, $5�
Sponsor(If other than appii ant) Address,City,State
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Location of proposed fireworks stand [Enclose drawing of stand location]
� �$" �)m �e �'
Manner and place of storage prior,during,and after sales dates �� �� b'-'� (`t ��"�
�7'�r�c� ; z � � th � se���r���' 7'a ,� .,J�r
State-Licensed Fireworks Supplier
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FIREWORKS STAND PE�IT
For the Fireworks Sales Year of: v2C��`]�
(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
c•� ,, �r��� as the local governing authority, the named person, firm or
organizati'on 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 July 4th Sales for December 31St
h
From: .�u�e ��� ��� From: /� �
To: a�; �. :31 - - .��i� To:
Sponsor
Location ��v►1 ��'e �
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S o Official Grantmg Permrt Signature of Applica�t
Title �,P� � � Agency �_ ,p♦ � �-�
Date Permit Number
Licensee Name License Number
3000-420-013 (R3/09)
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,nco�ra CERTIFICAT� OF LIABILITY iNSURANCE
6/10/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
' CERTIFICATE OOES 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), AUTHORI2ED
, REPRESENTATIYE OR PRODUCER,AND THE CERTIFICATE HOLDER.
� IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must be endorsed. If SUBROGATION iS WAIVED,subject to
i the terms and conditions of the poficy,certain policies may require an endorsement. A statement on this certiticate does not confer rights to the
certificate holder in lieu of such endorsement s.
' PRODUCER ' CON A T
�� NAME_--�—�- ____.
Britton Gallagher PHONE �— _
One Cleveland Center, Floor 30 EAMA��`►��-��5-7100 _ a���Fi��8=Z�__
1375 East 9th Street nooR€ss_
— —T—---
Cleveland OH 44114 INSURER(S)AFfORDING COVERAGE NAIC A __
---_ -___-
. INSURER A: fi C:p[]lpanv
INSURED 2567 -----�-------- -�----�-- - iNSUaER e:�v I�S In ity_I�u�nCe Co __ 2$`�1
Jake's Fireworks inc. �NSUReRC_
'i 1500 E 27th Terr.
—--- ------- --- �---
� INSURER D: _ __
' Pittsburg KS 66762 — -" ----
� INSURER E:
' INSURER F:
COVERAGES CERTIFICATE NUMBER:1186124927 REVISION NUMBER:
THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BFLOW 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 1MTH RESPECT TO WHICH THIS
CERTIFlCATE 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� —rADDL�BR� � : POLICY EFF j POLICV EXP
� lTR i TYPE OF INSURANCE R WVD POIICY NUMBER I MM/DD/YYYY , MM/DDJYYYY LIMITS
, 8 GENERALLIABIUTY iS18G100320-141 �/15/2014 2/75/2015 i EACiiOCCURRENCE __ �51,000,000
j DAMAGE TO RENTED
x�COMMERCIAL GENERAL UABILITY i ! ' PREMISES(Ea occurcence__ $500,000
I
, � �- --------
X ' � MED EXP(Any one person) $
! I CLAIMS-MADE OCCUR I I i
� -- �-------
;�� I fPERSONAL&ADV INJURY i$Z,000,000
{—J _ _ � h-- — ���
; i I I GENERALAGGREGATE I SZ,000,000
r--' ----------
i GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPfOP AGG $2,000,000 _ _
�� �� PRO- �� $
i POLiCY I i I I LOC
�: I AUTOMOBILE LIABILITY I I � jEa accidenQ_-- $—_--_._---
. I ANY AUTO � BODILY INJURY(Per person) $
� �....-. ,'ALL OWNED i � SCHEDULED j --- ---- —�--------�-
�� I i BODILY INJURY(Per accitlent)' b
'AUTOS �.__)AUTOS � --�— ---
i�� i NON-OWNED PROPERTY DAMAGE $ —
. � HIREO AUTOS AUTOS Per accidentj_____.__
. I I �--------
j
I A � � UMBRELLA uAe X p�CUR EXC6018367 �/15l2014 I/15/2015 EqCH OCCURRENCE __I 82,000,000 __
: �- --
IX 1'D�pESS��I RETENTION g CLAIMS-MADE_ j � � AGGREGATE $2,000,000
' , i I ------�$--- ------
I� I AND�Mp��COMPENSATiON . VvCSTATU- i OTH-�
� � OYERS'UABILITY I Y_LIM�S_i___-��R�._ .__...
�'�, ANY PROPRIETOR/PARTNER/EX.ECUTIVE� N�A I I E.L EACH ACCIDENT _ �; $ . _ __
OFfICER/MEMBER EXCLUDED?
II� �Mandatory in NH) I E L.DISEASE-EA EMPIOYE S
It yes,descnbe under
------------ —.
. I DESCRIPTION OF OPERATIONS below ; El.DISEASE-POLICY UMIT $
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DESCRIPTION OF OPERAT�ONS/LOCATIONS I VEHICLES �Attach ACORD 101,Aaditional Remarks Schedule,if more space is requlred)
Sales l.ocation: 1405 Yelm Ave. E., Yelm,WA 98592;
S&S Joint Ventures(Land Owner); City of Yelm and all its employees; Pacific Northwest Fireworks and all its employees; Yetm Christian and
ali its employees; Ken Kersey
Term: February 15, 2014 through February 14, 2015
The Certificate Hotder and the above listed are Additional Insureds with respects to General Liability policy as required by written contract.
CERTiFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE
THE EXPIRATION DATE THEREOF, NOTICE WI�L BE DELIVERED IN
City of Yelm ACCORDANCE WITH TNE POLICY PROVISIONS.
' 105 Yelm Ave. W.
Yelm WA 98597 AUTHOR2ED REPRESENTATIVE
�iF�+r��'
I
' O 1988-2010 ACORD CORPORATION. All righis reserved.
' ACORD 25(2010l05) The ACORD name and logo are registered marks of ACORD
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