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)
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