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20140236 Permit Pkg 09192014 �p� rH�a�� City of Yelm Permit ►vo.: 20140236 � 7 4 � Community Development Department Issue Date: 9/19/2014 (Work must be completed within 180 days) Building Division Phone: (360)458-8407 Y LM '".""'""°" Fax: (360)458-3144 Applicant: Name: YELM SCHOOL DISTRICT Phone: 458-6128 Address: P.O. BOX 416 YELM WA 98597 Property Information: Site,4ddress: 1315 YELM AVE W Owner: YELM SCHOOL DISTRICT Assessor Parcel No.: 21724210500 Subdivision: N/A Lot: N/A Contractor Information: Name: ENTERTAINMENT FIREWORKS Phone: Address: P.O. BOX 7160 OLYMPIA WA 98597 Contractor License No.: Expires: 0/00/0000 Project Information: Project: FIRE WORKS Description of Work: HOMECOMING HALFTIME FIREWORKS, OCTOBER 10, 2014 Fees: Item Contractor Fees FIRE ENTERTAINMENT FIREWORKS $ 0.00 TOTAL FEES: $ 0.00 ApplicanY Affidavit: OFFICIAL USE ONLY I certify tha I ha ea d examined the information contained within the application and know the same to be true orrect. I al o certify that the proposed structure is in conformity with all applicable City of #Sets of Prints: Yelm regul tions cludi those governing zoning and land subdivision, and in addition, all covenants, easements and tri � ns of recor If applying as a contractor,I further certify that I am currently Final Inspection: registered i the at shi t �7 Date: Signature e q (7 Firm By� TH1S FORM 1S INTENDED TO BE USED AS A GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING JURISDICTION AND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON WASHINGTON STATE PUBLIC FIREWORKS DISPLAY PERMIT Applicant Name of Event Yelm High School Homecoming Street Address 1315 Yelm Ave. W, City Yelm WA 98597 County Thurston Event Date October 10, 2014 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 Nicholas Olson General Display Company Name Entertainment Fireworks, Inc. Phone No. (360) 352-8911 Attach a separate piece of paper and/or copies of the following documents: • The number of set pieces, shells(specify single nr 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 diseharged; the tocation of all buitdings, highways, and other lines of communication; fhe tines behind which the audience will be restrained; and the location of all nearby trees, telegraph or telephone lines, or other overhead obstruction. • Documentary proof of procurement of Surety bond or public liability insurance. Local Fire Code Authority Authority Having Jurisdiction Name of Permitting Official �1r�( C��'�� �� Title �v�� t Vl.�l ��'i U C� Phone No. �nQ, � •���� v Permit Cyranted: �'Yes ❑ Yes, with Restrictions (see "Notations" below) ❑ No Restrictions/Notations 9 � z� Signature o er i ing fficial Dat of Ap oval ` Permit Number If approved, this permit is granted for the date and time noted herein under the authority of the International Fire Code in accordance with Revised Code of Washington 70.77 and a!1 applicable rules and ordinances pertaining to�reworks in this jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is responsible for any and all activifies associated with the firing of this show. MUST BE APPROVED BY THE AUTHORITY HAVfNG JURISDICTION 3000A20-050(R 3/13) A�°�s°mafi peFr�it ta Entertainmerrt Fireworks,fnc. ,��,yt'��i� �S , Post Office Box 7160 � .� F ��ympia,lNA 485Q7-7160 � (360�352-8411 Eax:(360�352-0205 �Nq��g� EVENT DATE- Octob�r I0,2i3i4 License Number:C-Q4085 SPONSOR/NAME OF EVENT: Yelm High Schooi Homecoming LOCATION OF DISPLAY: 1315 Yeim Ave.W,Yelm WA 98597 MANNER&PLACE OF STORAGE PRfOR TO DISPLAY(Subject to approval of Locai fire Authorityy Deiivered ta site day af display. ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DiSPLAY. Type of Firewarks Quantity Type of Fireworks Quantity .75" 1.4G Cfass"C"RamaR Cartdte Batons 2 1.75"Aerial Shells- 1.4G Ciass"C" 115 1.4G Class"C" Multi-shot Cake Devices up to 50 ALL ITEMS ARE 1.4G CLASS "C" SIGNATURE OF APPLlCANT: � � �— ' /� �.�.fi_.9�)�i-��1���!,�o�/.�// � ,��y7 �_ � � � i�' m�..w. . - �rmnnw�w�w�rnniw�wrrw�..r.r .. ACORO� CERTIFICATE 4F LIABILITY IIVSURANCE DATE(MM/DD/YYYY) Ii,° 9l15/2014 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 certi£cate dces not sonfer rights Eo the i certificate holder in lieu of such endorsemen s. PRODUCER NAME: f ; Arthur J. Gallagher Risk Management Services, If1C. PHONE Fnx I777 108th Ave NE,#200 ac No �:42 . 6.1 1 ac No:4 1 1 Bellevue WA 98004 E-MAIL i ADDRESS: I INSURER S AFFORDING COVERAGE NAIC# il INSURER A:T.H. fl INSURED ENTEFIR-01 �NSUReRe: rkshire Hathaw Hom In r 44 iEntertainment Fireworks, �I1C. INSURERC: 13313 Reeder Rd. SW INSURER D: Tenino WA 98589 INSURER E: � tNSURER F: � COVERAGES CERTIFICATE NUMBER:1468257407 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHlCH 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. ��� TYPE OF INSURANCE NSR SWVD POLICY NUMBER MMIDDY E�F MMIDD EXP LIMITS � A GENERALLIABILITY CPP0103972-00 15/2014 15/2015 EACHOCCURRENCE $1,000,000 ��� X COMMERCIAL GENER,4L LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence 5100,000 CIAIMS-MADE �OCCUR MED EXP(Any one person) $ I PERSONAL&ADV INJURY $1,000,000 GENERALAGGREGATE $2,000,000 ' GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PR� LOC $ B aUTOMOBILE LIABILtTY 02APM003612-01 15/2014 15/2015 Ea accident 1 000 000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERN DAMAGE X HIREDAUTOS X A�lTOS Peraccident $ -- $ A UMBRELLA LU46 X OCCUR EPL0011552-00 15/2014 15/2015 EqCH OCCURRENCE $1,000,000 X EXCESS UAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION$0 $ WORKERS COMPENSATION WC STATU- OTH- AND EAOPLOYERS'LIA&UTY Y�N T RY I IT I ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � N�A E.L.EACH ACCIDENT E (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POIICY LIMIT $ iDESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additlonal Remarks Schedule,ff more space is required) Certificate holder is included as an additional insured on the General Liability policy per form number CG133F(07/95). Date of Display: Oct. 10,2014. Location: Soccer Field next to Football Fie�d. Addl. Insured: Yelm High School;Yelm Community Schools; City of Yelm and Yelm Fire Dept.;their officers, agents, and employees when acting in their official capacity as such. , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yelm High School Yelm Community Schools ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 476 Yelm WA 98597 AUTHORIZED REPRESENTATIVE ' �.� .���_ i O 7988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I I � E ADDITIONAL INSURED- FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additionai insured: 1 . The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on beha(f of the Named Insured; but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. AI1 other terms and conditions of the policy remain unchanged. CG133F{07/95) � I ; � . � I O � !\ v` 4� � � .C7L7 I . ., . i� � � � o � � � � � P �_ , . . � Y � � � � I _ � � � 1 � t'"' � �"'� V I L. Q. C I •� � � � y �� � O N � I a � � , C. �' d � � .. 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