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20150170 Permit Pkg 04232015City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: YELM JESUS NAME PENTECOSTAL Address: 2120 MILWAUKEE WAY TACOMA WA 98421 Property Information: Site Address: 17100 SE STATE HWY 507 Assessor Parcel No.: 64303101000 Subdivision: N/A Contractor Information: Name: YELM JESUS NAME PENTECOSTAL Address: 2120 MILWAUKEE WAY TACOMA WA 98421 Contractor License No.: Permit No.: 20150170 Issue Date: 4/23/2015 (Work must be completed within 180 days) Phone: Owner: WALMART Phone: Expires: 0 /00 /0000 Project Information: Project: FIRE WORKS Description of Work: FIREWORKS STAND JUNE 28 THRU JULY 5, 2015 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item FIRE Contractor YELM JESUS NAME PENTECOSTAL TOTAL FEES: Applica 's Affidavit: I certify t t I have read and examined the information contained within the application and know the same to be tr $nd correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm re ulations including those governing zoning and land subdivision, and in addition, all covenants, easem nts an es ictions of r rd. If pplying as a contractor, I further certify that I am currently registe ed in a St a of Wa g o Signatyre 1 I 1Da te Firm Lot: N/A Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: City of Mi (36 } 458 -3244 REC #: 00193296 4/23/2015 11 :34 AM OPER: CO TERM: 001 REF #: 30034070 PAID BY: TRAN: 33.0000 BUILDING PERMITS 20150170 30.000R YELM JESUS NAME PENTECOSTAL 17100 SE STATE HWY 507 FIRE 30.00CR TENDERED: 30.00 CHECK APPLIED: 30.00 - CHANGE: 0.00 aol5o l � April 13, 2015 Community Development City of Yelm 105 Yelm Avenue West Yelm, WA 98597 Dear Community Development Official, In preparation for the upcoming 2015 4th of July season, please find enclosed with this letter all the documents to apply for 1 stand /tent fireworks permit. Also enclosed is 1 check totaling $30.00 to cover the permit fee. If you have any questions, please feel free to contact me at (253) 922 -0800, thank you. Sincerely, Sabrina Dick LicensingN @tntfireworks.com Licensing & Permits American Promotional Events, Inc. - Northwest Enclosure(s) AMERICAN PROMOTIONAL EVENTS, INC. 2120 MILWAUKEE WAY • TACOMA, WA 98421 TACOMA (253) 922 -0800 • FAX (253) 830 -2930 www.tntfireworks.com F2E EIVED APR 21 2015 � *SNWGTGN Sl4rF �F *ARSHAVS OAF\ Licensee Data Washington State Patrol Fire Protection Office of the State Fire Marshal`. CONSUMER FIREWORKS RETAIL SALES STAND t merican Promotional Events, Inc. 120 Milwaukee Way Tacoma, WA 98421 icense Number: WSPFL -02766 Phone Number: (253) 922 -0800 Stand Number: SN -09409 Operation 1 Dat` Wholesaler: TNT Fireworks x' County of Operation: Thurston Operates For: Yelm Jesus Name Pent. Chy Date of Issue:February 9, 2015 Date of Expiration - January 31, 2016 IN Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Years Sal This license is NOT valid without a permit from a local fire code official /authority having jurisdiction. This license allows for operation of a single location /stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. THIS LICENSE PORTION ACCOMPANIES YOUR LOCAL PERMIT APPLICATION YELM WASHINGTON City of Yelm SPECIAL EVENT /TEMPORARY USE ❑ Special Event Sign Permit ❑] Temporary Use Start Date: 6/28/2015 End Date: 7/5/2015 Applicant:YELM JESUS NAME PENTECOSTAL CHURCH Owner: GREG MATTOCKS Address: PO BOX 5390 Address: PO BOX 5390 YELM, WA 98597 YELM, WA 98597 Telephone: 360 - 400 -1588 Telephone: 360 - 400 -1588 Email: LicensingN @tntfireworks.com Email: Representative: GREG MATTOCKS Mailing Address: PO BOX 5390 YELM, WA 98597 Telephone: 360 - 400 -1588 Email: General location of the project: WALMART #3705, 17100 SR 507 SE, YELM, WA Assessor's Tax Parcel Number: Description of Project: TEMPORARY RETAIL FIREWORKS STAND RAN FOR FUNDRAISING PURPOSES Attach a site plan no larger than 11" X 17" showing the proposed development. Yelm City Hall 105 Yelm Avenue West Yelm, WA 98597 (360) 458 -3244 (360) 458 -4348 FAX www.d.yelm.wa.us FIRE PROTECTION BUREAU FIREWORKS LICENSING PROGRAM PO Box 42600 Olympia WA 98504 -2600 (360) 596 -3914 FAX: (360) 596 -3934 APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWT7150 TO Governing body of city, town, or county in which DATE OF JANUARY 22, 2015 fireworks stand will be located. APPLICATION Applicant Name Address, City, State YELM JESUS NAME PENTECOSTAL CHURCH 2120 MILWAUKEE WAY, TACOMA, WA. 98421 Sponsor (If other than applicant) Address, City, State GREG MATTOCKS 2120 MILWAUKEE WAY, TACOMA, WA 98421 Location of proposed fireworks stand [Enclose drawing of stand location] 17100 SR 507 SE, YELM WA WALMART #3705 Manner and place of storage prior, during, and after sales dates ON SITE WITH SECURITY State - Licensed Fireworks Supplier AMERICAN PROMOTIONAL EVENTS NW 2120 MILWAUKEE WAY, TACOMA, WA. 98421 FIREWORKS STAND PERMIT For the Fireworks Sales Year of: 2015 (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 CITY OF YELM as the local governing authority, the named person, firm or organization 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 From: From: To: 1� /�o� t— To: Sponsor /GREG MATTOCKS Location WALMAR S, 17100 SR 507 SE, YELM, WA /sl ` - /s/ /3 � FOR GREG MATTOCKS Signature of Official Granting Permit Signature o Applicant Title 3c,,`d 6 t Agency Date Permit Number Licensee Name YELM JESUS NAME PENTECOSTAL CHURCHLicense Number 3000- 420 -013 (R 3/09) C7 Letter of AUthortz(.i ion Project Wnrk Order — Dept 86 Fireworks Event ?n: American Promotional Events, dba TNT Fireworks #608872 f tor;. Merchandise Execution -Walmart Services Da e: December 23, 2014 RU., TNT Fireworks Parking lot Promotion Dear Valued Supplier, Thank you for your continued support and collaboration. This Letter of Authorization ( "LOA ") outlines the project you have agreed to complete. Only your employees or approved third -party representatives {co(lectively "Representatives' may perform the project on your behalf. You must ensure your Representatives produce credentials to store management showing that the Representative has been authorized by you to perform the project on your behalf. All tasks outlined in this LOA must be performed in accordance with the terms, conditions, and requirements of the Walmart Supplier Agreement and /or the Walmart Master License Agreement. Prolect Overview: - Purpose: To conduct fireworks promotions on the parking lot Stores Affected: Preliminary store list attached (pending permitting/ licensing approval) - Project Timeline: June 17, 2015 through July 08, 2015. Stores in UT July 18, 2015 through July 25 2015. The authorizations granted to Supplier by this LOA expire at the end of the Project Timeline. If Supplier is hiring a third party to staff the project, list the company here: N/A Supplier Responsibilities: 1) Check in at the Customer Service Desk upon arrival at the store and sign In on the Vendor Log. 2) Ask for the Store Manager ( "Manager") or Front End Zone Merchandise Supervisor ('ZMS'), present this letter of authorization to him/her, and obtain the signature of a salaried member of store management. Y Note: If Store Manager or Front End ZMS is not available, ask for another Assistant Manager within the store. 3) After presenting this LOA to the applicable Manager or ZMS, inform him/her that you will be executing the following steps: Step #1 — Introduce the Company, explain the program, discuss participation in the event and validate proper placement on the parking lot. Step #2 — TNTS Fireworks will obtain all necessary permits and/ or licenses associated with a fireworks event on the parking lot. TNT to provide proof to stores of permit/licensing. Step #3 — TNT(D Fireworks (or authorized 3`' party representatives) will set up the event on the parking lot in the space approved for the event and will conduct sales during the dates listed in the attached (which will also be communicated by the HO)_ Walmart grants permission for all patrons of the sale to utilize the restroom facilities. In performing the LOA, Supplier must: • Ensure its Representatives execute only the steps listed in this LOA; Prohibit its Representatives from giving directions to or receiving directions from Walmart's associates except for directions listed In this LOA; • Prohibit its Representatives from disrupting Walmerfs normal store operations; Prohibit its Representatives from entering the backroom or any other "associate only" designated areas (unless Representatives are SPARC certified or escorted by a Walmart associate); ® Prohibit its Representatives from using Walmart power lifting equipment to perform this LOA; ® Prohibit its Representatives from opening locked cases on the sales floor (e.g., electric shavers, firearms, etc.); and Property vet its Representatives to ensure that their employment status complies with applicable law, and that they do not pose a risk to the safety or property of Walmart, its associates, or its customers. Supplier may not solicit the general public to perform these tasks through web -based applications, inciuding, but not limited to, Gigwalk or Field Agent. Under this LOA, you are an independent contractor. As such, neither your action nor inaction may be attributed to Walmart. Your Representatives are not Walmart's employees and have no authority to act on Walmar's behalf. Any questions concerning this LOA should be directed to the Walmart associate identified below or a member of Store Management. Best regards, /L Director r. Drector Walmart M ndise Execution Supplier's Vendor #: 608872 Supplier's Master Supplier /Services Agreement is active: yes o no X Kent bliver Director Walmart Services Agreed and accepted this 2ry'day of J&nUCLV , 20 ISby: SUPPLIER NAME (TNT Fireworks) Bo Castle Vice President TNT Fireworks Fundraising Proiect Name: Fireworks Sale§ on Parking lot Store Associate (Manaclement) Responsibilities: 1) Check Event Calendar Plus Week 48 to verify that this LOA has been approved by Walmart; 2) Sign this LOA acknowledging the Representative's visit to the store; and 3) Ensure the space on the parking lots is available to the Representative so the tasks may be executed. STORE MANAGEMENT ASSOCIATE [Manager signs here once the project has been completed] Name: (print name) Title :L'!, title] Date: Tprint date] ACORO" CERTIFICATE OF LIABILITY INSURANCE �� 1 1/1 /2015 DATE (MM /DD /YYYY) 1 /20/2015 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lockton Companies NAMECT 3280 Peachtree Road NE, Suite #250 Atlanta GA 30305 (404) 460 -3600 PHONE FAX Ext : A/C No E -MAILo ADDRESS: COMMERCIAL GENERAL LIABILITY Y N INSURERS AFFORDING COVERAGE NAIC # INSURER A: Everest Indemnity Insurance Company 10851 INSURED American Promotional Events, Inc. 1359629 DBA TNT Fireworks. Inc. INSURER B $ 500,000 INSURER C CLAIMS -MADE OCCUR INSURER D P.O. BOX 1318 4511 Helton Drive Florence AL 35630 INSURER E INSURER F COVERAGM I / I " 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD /YYYY POLICY EXP MM /DD /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y N S18GL00242 -141 11/1/2014 11/1/2015 EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 CLAIMS -MADE OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ PE� ❑ LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE (Ea accident) SINGLE L I $ XXXXXXX BODILY INJURY (Per person) $ XXXXXXX ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ XXXXXXX PROPERTY DAMAGE fPer ,,r $ XXXXXXX NON -OWNED HIRED AUTOS AUTOS $XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX EXCESS LIAB CLAIMS -MADE 77DED RETENTION $ $ XXXXXXX WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N NOT APPLICABLE STATUTE E R E.L. EACH ACCIDENT $ XXXXXXX ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? F-1 N/A E.L. DISEASE - EA EMPLOYEE $ XXXXXXX (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ XXXXXXX DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERMS) REFERENCED. 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 CITY OF YELM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE YELM JESUS NAME PENTECOSTAL CHURCH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 749 YELM WA 98597 AUTHORIZED REPRESENTP,LT_(VE� %f // f�" �_"✓✓""SS _ i ACORD 25 (2014/01) ©1988- 201 ,TACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SITE DIAGRAM m March 17 ate Drawn: , 2008 Address 17100 State Route 507 SE Store /Center: Wal -Mart Superstore City & State: Yelm, Washington Cross Streets: GPS Co- ordinates 46.56.003 N 122.37.725 W m s� Light House Entrance C; X IL 63' Loc No: WVvT.7 150 Ordinance of: City of Yelm Parcel No: Tent Faces Direction of: Open To The North Tent Size: 20 x 40 Notes: DO NOT STAKE TENT a WATER BARRELS OR CEMENT BLOCKS ONLY Fire & Lube Main Entrance Grocery Garden Center Wal -Mart ss0'+ 40' 1 30' 20 X 40 Tent Trellis _____ Light L HWY 507 Open Field --- ---_Sidewalk ------------- ca i �a Grass O co J W O N m F— Z Y J X W 69 I!X3 m 46669 T!Xzl c� U CIO I9 o U 4-0 J-1 L T 0) W N L_ LL KNI W T 4 • M O 7 O T (U C N C) O N O V Cert "f g� ate. of I-,lame i 4� a9 �� REGISTERED ISSUED By i Fabric �F,o<J. 7 Drrnc,rvfeer1� 0° 9 M rr i cl i a n m et n u f a e e u r illy, POPlar Ave., Ste. 1432 MvI?'pIfis, TN 38157 d 5 This is to certify that the materiels described on the reverse side hereof hovo been name - retard0nt treated (or are inherently nonflammable), FO Key Ha nufacCuring & RencaI ADDRESS 503 xoc-lcrl.t a s L CITY Brooks Certification is hereby made that: (Check "aJe or (a) The articles described on the reverse side of this Catficate have teen treated with n flame- vetordanI chemical appeoved and re57istmred by she $late Fire Marshal and that the application of surd chemical was done in conformance with the lags ®f the State of California and the Rules.antl >Zegdchit i of the State Fire Marshal. Name of chemical used .............. .....__Chem. Rao. No........... Method of ap plication .. ............................... (b) The articles dwscribed on the rm^/erte aide hem# are mods Frans o home- resistant fobr.: or rnalwriat rvotsivr+sd and oppr000d by t6 5taft Fire Marshoi for s x:h use. Trade name of flonle- resistant fabric .. Group 1 into- M t t is�5 The Flame Retardant Process Used i.,I 1....11o1... Be Removed B)' Washing Moir ab em11f'i,oai g Jinsmie Rabereson Aroma of Applivnor or Pmdvstion $u�orinlendsnd CONTROL NO. 14 8 2 4 CUSTOMER ORDER NO, L 227 CUSTOMER INVOICE NO_ 80222 YARDS OR QUANTITY— 750 yard s COLOR STYLel"?" II White Chrome DATE PROCESSED 1-12-96 By (.,