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FIRE-05-0307 63>7 - /13~ City of Yelm Community Development Department Building Division Phone: (360) 458.8407 Fax: (360) 458-3144 Permit No: SE-04-0162-YL Issue Date: 10/07/2004 (Work must be started within 180 days) Receipt No: Applicant: Name: Childs Fireworks Phone: 253.531-1658 Address: P.O. Box 45637 City. Tacoma State: WA Zip 98445 Property Infonnation: Site Address: 1315 Yelm Ave. West Assessor Parcel No. 21724210500 Subdivision: Lot: Contractor Infonnation: Name: Contact Phone: Address: City. State: Zip: Contractor License No: Expires: Business License: Project Infonnation: Project Yelm High School Home Coming Description of Work: Aireal Fireworks Display License #P-4019 Sq. Ft. per floor. (1st) 0 Heat Type (Electric, Gas. Other): (2nd) 0 (3rd) 0 Garage 0 Basement 0 Fees: Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Desc TOTAL FEES. $0.00 Applicant's Affadavit: OFFICIAL USE ONLY 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 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 futher certify that I am currently registered in the State of Washington. s."'~ Ira,~ Dole /1)."(- -'f Firm # Sets of Prints: Final Inspection: Date: By' City of Yelm Community Development Department Building Division Phone: (360) 458-8407 Fax: (360)458-3144 Permit No FIRE-05-0307-YL Issue Date 09/27/2005 (Work must be started within 180 days) Receipt No Applicant: Name: Childs Fireworks Phone. 253-531-1658 Address. P.O Box 45637 City' Tacoma State: WA Zip 98445 Property Information: Site Address. 1315 Yelm Ave. West Assessor Parcel No 21724210500 Subdivision: Lot: Contractor Information: Name. Contact: Phone: Address. City' State. Zip' Contractor License No: Expires. Business License. Project Infonnation Project: YHS Home Coming Description of Work: Fireworks display at Home Coming License # C-04188 Sq. Ft. per floor (1st) 0 (2nd) 0 (3rd) 0 Garage 0 Basement 0 Heat Type (Electric, Gas, Other): Fees. Item Item Fee Base Amt Unit Fee Unit Rate No. Units Unit Oesc TOTAL FEES $0.00 ?,'-J~\......~ Applicant's Affadavit: y~ N ~ Sh~c. ~: spJf4t} I certify that I have read and examined the information contained within the application and know the same to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm regulations including those governing zoning and land subdivision, and in addition, all covenants, easements and restrictions of record. If applying as a contractor, I futher certify that I am currently ""'''"ed '0 the Stole ~ogt'" OFFICIAL USE ONLY # Sets of Prints. Firm Final Inspection: Date: IIJ.J& I / By' ~NY { OJ ~~~~~~~~~~~~~~~ -eOMM. JOURNAL- ~~~~~~~~~~~~~~~~~~~ DATE SEP-26-2005 ~~~~~ TIME 20:47 ~~~~~~~~ MODE = MEMORY TRANSMISSION START=SEP-26 20:46 END=SEP-26 20:47 FILE NO.=164 STN No. eOMM. KEY NAME STATION NAME/EMAIL ADDRESS/TELEPHONE NO. PAGES DURATION 001 OK fi 912535311738 001/001 00:00:13 -Yelm eDD ~~~~~ DP-3520 ~~~~~~~~~~~~~~~~~~~~~~ -Yelm eDD - ~~~~~ - 360 458 3144- ~~~~~~~~~ .J'T ~ CityofYelm ~~ .1 Community Development Department ~. Building Division Phone: (360) 468-8407 __. F/llC: (3601458-3144 Applicant: Permit No: FIRE-oS-o307 -YL ISSUll Date: 09/27/2006 (WOrk mu&t be &tened within 180 days) Rllceipt No: Name: Childs Fireworks Phone: 253-531-1658 Addre&6: P.O. Box 46637 City: Tacoma Stale: WA Zip 98445 Property lnfonnatlon: Site Address: 1315 Yelm Ave. West As.essor Parcel No. 21724210500 Subdivi.ion: ~ot: Con1ractor Information: Name: ContaCI: Phone: Addra6s: City' State: Zip: Contractor ~icense No: Exp"es: Buslne&$ L1c&nsa: Project Infonnation: Project: YHS Home Coming Oascnptlon of Work: Fireworks display at Home Coming ~icenge 1# C.04188 Sq, Fl. per floor: (1st) 0 (2nd) 0 (3rd) 0 Haat Type (Electric. Gas. Other): Garage 0 Basement 0 Fees: Item Item Fee Ba.e Amt Unit Fee Unit ~'Ie NO. Units Unit Oasc TOTA~ FEES: $0.00 Applil:ant'a Affadavit: OFFICIAL useONL Y '1# Sets at Print9~ I cenify that I have read and axamlned Iha InlormatlOn contained within tha application and know tha &eme to be true end correcl. I also certify thet the propo~d structure i. in conformity with an epplicable City of Y41m regulations including Lnose gO'ol'erning zoning and land subdivision, and in addition, a.1I covenants, easements and reslrictions 01 record. If applying as a contractor I futher certify thai I am curranlly registared in lhe Stale of Washington. Signalure Firm Dale Flnallnapectlon: DaI8:' By: ;2 7 ~~ September 26, 2005 Mark/RIta Thurston County FIre Dlstnct, 2 Childs FIreworks carne m Fnday for a permIt for home commg next Fnday See any problems. Thanks Gary Carlson APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT DATE OF APPLICATION 9-22-05 TO. Governing body of city, town or county in which display is to be conducted. APPLICANT ~~ids' Fireworks SPONSOR elm i h h 1 PYROTECHNIC OPERATOR NAME John E. Childs NAMES OF ASSISTANTS: NAME Box 45637 Tacoma, WA 98445 PHONE 253-531-1658 PHONE Tacoma WA 98445 4019 puyallup, WA 98373 AGE 50 AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION 1315 yelm Ave. Yelm, WA 98597 in DATE 9-50-05 E A 01 F 270- 0.50 inch. fields west of the football fiel 7:00 to 10:00 P M 10- 2.00 inch. salute 5- 1.50 inc Candles 3- 2.00 inch. candles 3- 2.00 inch Comets 35- Cakes 11 1.3G 24 1.4 roval of Local Fire Authorit FINA.NCIA.L. RESPONSIBILITY BONDING OR INSURANCE CO COMBINEB SPECIALTIES INT'L ADDRESS 8362 Tamarack Village # 119 Woodbury, MN 55125 (Mark One) Bond or certificate of insurance attached o Bond or certificate of insurance on file with State Fire Marsha Bond or certificate of insurance shall provide minimum coverage of $50,000/$1 ,000,000 bodily injury liability for each person and event, respectively, and $25,000 property damage I I PART II PERMIT /' <r/dyu)- PERMIT# rJq _ b<- o3~?-'1L DATE. , In accordance with the provisions of RCW 70 77 and applicable local ordinances this permit is granted to conduct a fireworks display as per the above application NAME Childs' Fireworks Display Co. t Inc. (Full name of person, firrn or corporation granted permit) RESTRICTIONS. -;;:J Permit not valid without verification of ~~ of Offi",' gca,tlng.pe<mlt) State General Display License 3G...uT 0'12:-2- LICENSE NUMBER C -04 188 (Title) (Instructions on reverse side) Distribtuion: WHITE (A): Local Fire Authority; YELLOW(B) State Fire Marshal's Office; PINK(C): Permitee 3000-420-050 (R 01/01) APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT DATE OF APPLICATION 9 -22 -05 TO Governing body of city, town or county in which display is to be conducted APPLICANT ~~lds' Fireworks SPONSOR Yelm T-iip'h :", n1 PYROTECHNIC OPERATOR NAME John~. Cnilds NAMES OF ASSISTANTS. NAME p' i NAME 45637 '['82oma, i~ r ,A 1..'1. 98445 PHONE 253-531-1658 PHONE '1'a c'}mc 'fA 98445 4019 -;+ T' "puyi:illup, ,'Ie:. 98373 AGE 50 AGE EXACT LOCATION OF PROPOSED DISPLAY LOQA TloN 1)1, yelm :ve. yelm, DATE 9- ..50-05 yi;'.. 985 j7 in ti1e .D,n 1 fie los 1,I,e st ,)f the football fie 1 TIME 7:00 to 1 0 : OC 1: (v1 Candles 162- 10- 2.00 inch. salute j- 1.50 inc ~andles 3- 2.00 inch. ~andles 3- 2.0U inch ~omets 35- Cakes 11 1.3G 24 1.4 roval of Local Fire Authorit 1101 i VDT'O ; q"""'; i ';)"\T nY' T fIi (~ FINANCIAL RESPONSIBILITY BONDING OR INSURANCE CO ADDRESS 23b2 Tam~r8ck Vill?ge T 119 ~ooQbury, MN 55125 (Mark One) Bond or certificate of insurance attached o Bond or certificate of insurance on file with State Fire Marsha Bond or certificate of insurance shall provide minimum coverage of $50,000/$ 1,000,000 bodily injury liability for each person and event, respectively and $25 000 property damage ('(lMBIN2D 3PE~IA1Tli~~ INT'L PART II PERMIT PERMIT# /':;.4/ _ b <"- o3~7-"IL DATE cr/.J7~)'- , 7' In accordance with the provisions of RCW 70 77 and applicable local ordinances this permit is granted to conduct a fireworks display as per the above application NAME Childs' FirewJrks liisplay ~o., Inc. (Full narne of person, firrn or corporation granted permit) RESTRICTIONS. Permit not valid without verification of State General Display License J ~'e of Off',",'.!1'!'~...mitl 3~'~;r t:f;2:g (Title) LICENSE NUMBER C-04128 Washington State Patrol 4 9 4 6 Fire Protection Bureau Office Of The State Fire Marshal P\'rotechnic Operator: License Number: Type of Liceri~ Expiration Datc,: JohnE. Childs :e~.qQ. ~~ 9 \~y-r ,mic Operator t"1. J/n ,: '1, '2006 Receiveci SEP 2 2 2005 \Vashington State Patrol 4925 Fire Protection Bureau Office Of The State Fire Marshal gene.ral Display: License Number: Tvpe of License:, Phone Number: , Ex ita' Crilds Fireworks Display Compan ,QgG4.-t88i: i1{ . ., :~~n. :1#l='lay .,\.,. ' (2$3 . "'; ,.11-658 \. . !f.'1l1lf~ / o gCJFd Washington State Patrol 4 9 2 6 Fire Protection Bureau Office Of The State Fire Marshal Importer: Yelm High School Product for Homecoming 2005 l.4GPyrotechnic 270 roman Candles for candle cannons 144 Smgles, Doubles and Tnples I 75 shells 15 small cakes 125 to 300 grams (19 shot) 9 large cakes 500 grams (16 shot) 1.3G Pyrotechnic 12- 1 75 mch. Special Shells 6 - 1 75 lOch. Salute Shells 10 - 200 lOch Salute Shells 3- 1 50 lOch. candles 3- 2.00 lOch. candles 3- 2 mch comets 8- small cakes (25 shots) 3- large cakes (15,30 or 50 shots) '-v '-~v,' "..., ''J -<oJ ~:. . . <,-~......;.. _..._:7~-::;~-= .h o:-ci:~:::;C' rim--' 'of! . ~. :~,:,-:::. .. ~_.:'-:~: '... -:-: .--.::;..:....;,......:.:. ...._.....d~~ -.---,...... ." -_.~:..~-~-~---,-'....,......,. - e ca: e-o . nsurance. ,n .-~--~. . .'. '.. . -_._~-_..~. ~~. .~~~~~:": ~=~:~: _.~~~~:'~~~~:=~~:~~~:~~~=::~3;~a{j~~ ~~ ;'~-;-:?~:~~::.F=~~Diii~ci9~~ PRODUCER THIS CERTIFICATl; IS ISSUED AS ~ MAneR OF lNFORI\IATlON ONl. Y AND Combined Spo,I:I:IItIe$ 111temo111orn1l. Inc. CONFEFIS NO flIGHTS UPON THE CERTIFICATE HOlDER. THIS CERTIFlCAlE 8362 Tamarack Village DOES NOT MEND, EXTEND OR LATER THE COVERAGE AFFORDED BY THE Suite 119 I>OUC1ES BELOW. WlIDllbuly MI~lil55'2S INSUREflS AFFORDING COVERAGE INSURER A. Unde_bers. LIoyd$ 01 LondOn INSURED INSURI;R 8: Child5 FII8WOIks Oiapby Co~ Ine. INSUREA C: f>.0. Box 45637 Tacorns W8~hInoton 90445 ,no COVERAGES THIS 1$ TO CERTIFY THAT THE POlICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAUED INSURED ABOIIE FOR THE Pfl:t1Ol) INOICATEO. NOTWITHSTANDING ANY REQUIREMENT', TERM OR CONDITION OF N4Y CONmACT OR OTHER DOCUMENT WITH REsPECT TO WHICH THIS CERTIFIC~TE MAY BE ISSUED OR MAY PERT~IN. 'T)fE INSURANCE AFFORCED BY ll-lE POUCtES OESC~IlED H~ IS SU9JECT'TO All Tl1E TERMS. exCLUSIONS AND CONorTIONS OF SUCH POLICIES INCLUDING. BUT NOT UMITED TO lliOSE FOUOWlNG: LIMITS SHOwN MAY HAVE BEEN REDUCED BY PAID ClAIMS. AOOmoNAL CQNOfflONS ANtI EXCLUSIONS. " THE INSURANCE EVIDENCED BY THIS CERTIFlCATt: IS L1~Il.J'tY INSURANCE ONL. Y IT IS NOT A BOND OR ANY FORM OF SURETY AGAINST WHICH SOMEONE OTHER AN 'NSUFlEO" MAY ASSERT A ClAIM OR BRING ANY AC'TlON. SUBJECT TO f>O\Jc;y TERMS. CONOfTlONS. DEFINll10NS AND EXClUSIOt>lS THE IN$URANCE ON\. Y INDEMNIFIES AN INSURED AGAll\IST CERTAIN LEGAL LIABILITY 2J THE INSURANCE OOES NOT COVER ClAIMS FOR BOOIL Y INJURY OR PAOPEATY DAMAGE OF THE NAMED INSURED'S SHOOTEA(S) ASSISTAHT(SI OR AN"( OTHER PERSON(S} INCl.UDING ANYVOUJTEERlS) PARTICIPATING IN AHY WAY IN ANY DISPlAY OR SPECIAL EFFECT PERFORMED OR EXE:CUTEO BY THE !'lAMED INSURED 3)COVERAGE DOES NOT APPI. y TO CLAIMS FOR 9O0ll Y INJURY OR PROPERTY DAMAGE ARISING our OF THE INSIJRECTS FAIl.URE TO FOU.OW NFPA OR OTHER APPLlCA8l.J; R~.LAWS OR RECOMMENDATIONS, INCUJDlNQ THOSE REl.ATING TO POST DISPLAY OR SPECIAl EFFECT SEARCHES OR CLEAN UP CO TYPE OF INSURANCE POLlCY NUMBER POLICY EFFECTIVE "'OL.ICY EXPIRATION LIMITS LTR DATE (MMIDDIYVl DATE (MWDDN"YI A GENERAl. LIABILITY , , , 6370616/005 June lIS, 2lI05 JlIhC 05, 200G EACH ACCIDBIT SS./lllO.DDD ClAIMS MADE MEDICAL EXP $$.000 r......_per_) FIRE lECAI.. LIABilITY S5D .000 CENE~ AOCREGATE SS.Ooo.ooo f>RODUCTS-COMPIOPS AGG S, .000.000 AlITOMOBllE UABIUTV COMBINED SINGLE LIMIT S fEfI ea:idonI\ ANY IlUTO BODIl y I~URY S IWY OWNED AUTO (per petlIIIn\ SCHEDUlED AUTOS BOOllY INJURY S HIRED AllTOS NON-OWNED AUTOS fPer acddenll PROPEmYOAMAGE ~ fPcr .........an) EXCess LIA8ll.lTY EACH ACCIDENT FOLLOWING FOAM Ar.GREGATE WORKERS COMPENSATION ~STAiU- OTHER AND ORV UMITS EMPLOYERS' UASILlTY LEACHACClDENT EL DISEASE-EA EMPLOYER S E.L. DISEASE-POl.\CY LIMIT S OTHER DESCRIPTION OF OPERATIONSlLOCATIONSIVEHIClfSIEXCI.I)SIONS ~DOEO BY ENDoRSEMENTISPEClAl PRQVISIOIIIS Yefm S~hOOI Dlslfld and City aI Yelm & BIllI1loy~ 1I~ A61lcllllonallMurOCl :l$ nl$Jl9ClIi the September 30. :!DOS F'_ks Oi9plar In balllle/d$ ~ Of Nlolb3ll field, at 131:; Yclm ~"onuo WlI$l Yelm. WA CERTIFICATE HOL.OER CANCElLATION Iv~ School OIslr\d SHOULD ANY' OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ll-lE EXPIRATION OATE le'/' 1~ $1ICO\ North THEREOF, THE ISSUING COMPANY WILL 8IIOEAVOR TO MAIl 10 DAYS WRfTTEN NOTICE TO THE Yelm. WA 98597 CEFlTIF~TE HOLDER NAMED TO THE LEFT BUT FAIUJRE TO NIAlL SUCH NOnce: SHAU.IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY IT'S AGENTS OA Rt:PRCSieNTATWEs 1\1 fTl.ln~11 NT"TNE~ C<Zi-- - ~-~--~-- C:Jf<.A tv iJ ; /'- .... 1'- ':> ",4- ~ ,,\ ...!- <..:t. ,~ ~ .~\\..) 3,\- :\ ~' ,;' -I ,~\ 0 '" "---- " " ...----- -~ , ~ ~. -L '.0 o -< ) \j." i c 'I "i --r 1'- ~...... '-- -L -\-.. ./ r: ; ,\ ~ --.....( \\J. >-- /' I \ l' ~I ~ .f::- ;::;' Cj ~ ~ ...;! ~ ____ f ~ ~____~___ /' ./ '~~~~::1/ - / / ,..... -".' " I'- d " :5 ~ ~~~ ci \-u ~ '" ~-~ - _. <i r Ci~-= \d. 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