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
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