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20150215 Permit Pkg 06192015City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: GOT FUSE FIREWORKS Address: PO BOX 1106 MCKENNA WA 98558 Property Information: Site Address: 1 r%A7R HWY -r%n7 SF Assessor Parcel No.: 64303400501 Contractor Information: Name: GOT FUSE FIREWORKS Address: KEN KERSEY PO BOX 1106 MCKENNA WA 98558 Contractor License No.: Project Information: Project: FIRE WORKS Description of Work: FIREWORKS STAND Sq. Ft. per floor: First Second Third Garage Basement Fees: Item FIRE Permit No.: 20150215 Issue Date: 6/19/2015 (Work must be completed within 180 days) Phone: 2532080489 Owner: RICK CHRISTENSEN Subdivision: Lot: Phone: Expires: 0 /00 /0000 Heat Type (Electric, Gas, Other): Contractor GOT FUSE FIREWORKS TOTAL FEES: Applicant's Affidavit: 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 further certify that I am currently registered in th S to of h" gtork,_. Signature / Date Cp Firm Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: City of Yell (36) 458 -3244 REC #: 00198874 6/19/2015 9:25 AM OPER: CO TERM: 001 REF #: PAID BY: TRAM: 33.0000 BUILD14G PERMITS 20150215 GOT FUSE FIREWORKS 16628 HWY 507 S3 FIRE 0 OOCR TENDERED: 40.00 CASH APPLIED: 30.00 - CHANGE: 10-00 L CITY OF YELM COMMERCIAL BUILDING PERMIT APPLICATION FORM Project Address: 11 98S_`Q Parcel #: Zoning; Current Use: Proposed Use: New Construction ❑ Re -Model / Re -Roof / Tenant Improvement Plumbing :j Mechanical ❑ Fire Prevent/Suppress /Alarm 01015o vs }Other Project Description /Scope of Work: /i �, {r (�Sf I jr2f- 1G21L� S rAND Project Value: Building Area (sq. ft) Parking Garage 1St Floor 2nd Floor 3rd Floor Building Height Are there any environmentally sensitive areas located on the parcel?_ If yes, a completed environmental checklist must accompany permit application. BUILDING OWNER/TENA�/NT NAME: C ADDRESS J�c "� -1 '. 6/ 1y, s-O 7- EMAIL -CCM CITY SQL �F�l STATE %�f ZIPI7- TELEPHONE ' - GI ARCHITECT /ENGINEER LICENSE # ADDRESS EMAIL CITY STATE ZIP TELEPHONE GENERAL CONTRACTOR TELEPHONE ADDRESS EMAIL CITY STATE ZIP FAX CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE # MECHANICAL CONTRACTOR TELEPHONE ADDRESS EMAIL CITY STATE ZIP FAX CONTRACTOR'S LICENSE # EXP DATE CITY LICENSE # Copy of City Mitigation documentation JFCI. I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the above described property will be in accordance with the laws, rules and regulations of the State of Washington and the City,pf Yelm. Applicant's SignaftGre / Owner / Contractor / Owner's Age / Contractor's Agent I Tenant Date (Please circle one.) All permits are non - transferable and will expire if work authorized by such permit is not begun within 180 days of issuance, or if work is suspended or abandoned for a period of 180 days JUN 12 2015 (360) 458 -3835 105 Yelm Aue W (360) 458 -3144 FAX Yelm, WA 98597 www.ci.yelm.wa.us FIRE PROTECTION BUREAU FIREWORKS LICENSING PROGRAM PO Box 42600 ®m �® Olympia WA 98504 -2600 VDAHINGM STAN PATRM 4 .. ""b o (� (360) 596 -3914 FAX: (360) 596 -3934 APPLICATION FOR RETAIL FIREWORKS STAND PERMIT TO Governing body of city, town, or county in which DATE OF fireworks stand will be located. APPLICATION f �s Applican ,ame { G ei7 heft Address, City, State �,/ �/ 1106/ % e/� �r�a � k/4f p8ssff Sponsor (If other than applicant) Address, City, State Location of broposed fireworks stand [Enclose drawing of stand location] 1 �� �4 670 � e-1 M , L44e �� 7 Manner and place of storage prior, during, after sales dates /and < Ors' i .1 / �4� Wi /l P. JeC4Pi ST��PIi�r�A �u I �i 1 e�4v�eo PO W C54 State - Licensed Fireworks Supplier 19CCG ?C / ►� 0 knee$ �c rC U/0 f FIREWORKS STAND PERMIT For the Fireworks Sales Year of: '02 (Must be conspicuously displayed at all times while the stand is open to the public) By virtue of havin been granted a license by the State of Washington and this permit from C;T'z/ o�em 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 From: T4A(' "0 1 A01 s To: Z-14 Sponsor n/ //f Sales for December 31St From: To: Location / 6/ 28 Stoll '�r —67 , Y4rt'! /s/ Signature of Official Granting Permit h- .7 /s/ ignature of App ant Title u Agency Date Permit Number Licensee Name License Number 3000420 -013 (R 3/09) ��N \NGTOMST,TF Washington State Patrol Fire F�roecfonureau Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES STAND LICENSE 15 -095 9F'd4RUM:$ 04`40 Licensee Data Got Fuse Fireworks P.O. Box 1106 McKenna, WA 98558 License Number: WSPFL -02065 Phone Number: (253) 208 -0489 Stand Number: SN -1003 Operational Data Wholesaler: Pacific Northwest County of Operation: Thurston Operated For: Licensee Stand Operated By: Ken Kerso Date of Issue -May 1, 2015 Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Y This license is NOT valid without a permit issued from a local fire code official /authority having jurisdiction This license allows for operation of a location /stand only for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. =- THIS PORTION OF THE LICENSE MUST BE POSTED AT THE STAND AT ALL TIMES Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit issued 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. SURRENDER THIS PORTION OF THE LICENSE TO THE FIREWORKS WHOLESALER;' �pgy, \NGTOMSTgTF Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES STAND LICENSE 15 -0952 FF'N4RgMpCg OF\`0 Stand Number: SN- 10037. Licensee Data Got Fuse Fireworks P.O. Box 1106 McKenna, WA 98558 License Number: WSPFL -02065 Phone Number: (253) 208 -0489 erational Wholesaler: Pacific N County of Operation: Thurston Operated For: Licensee Date of Issue:May 1, 2015 Date of Expiration. January 31, 2016 Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Years Sales 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 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 ACORt7� CERTIFICATE OF LIABILITY INSURANCE E (MMI DDIYYYY) 6/11 DATE 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 Britton Gallagher One Cleveland Center, Floor 30 1375 East 9th Street CONTACT NAME: PHONE FAX a/c No Ext:21 - 8 -7100 Alc No: 1 - -7101 E -MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Cleveland OH 44114 _ INSURERA:Ma um Indemnity m n /15/2015 /15/2016 INSURED 2567 INSURERB:Everest Indemnity Insurance Co. 10851 X COMMERCIAL GENERAL LIABILITY Jake's Fireworks Inc. INSURER C: 1500 E 27th Terr. Pittsburg KS 66762 INSURER D - $500,000 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1899418751 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 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 INSR SUBR---- WVD - - - - POLICY NUMBER -- MM/LDDY� -- MMIDD/YYYY LIMITS B GENERAL LIABILITY S18GL00320 -151 /15/2015 /15/2016 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence) $500,000 CLAIMS -MADE 1X I OCCUR MED EXP (Any one person) $ PERSONAL BADVINJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000,000 $ JECT POLICY PRO LOC AUTOMOBILE LIABILITY Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS A UMBRELLA LIAB X OCCUR EXC6018367 /15/2015 /15/2016 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 X EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN WC STATU- OTH- TORY I I IT ANY PROPRIETOR /PARTNER /EXECUTIVE E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED) ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Sales Location: 16628 State Route 507, Yelm, WA 98597 Land Owner: Rick Christensen; City of Yelm and all employees; Christensen's Furniture and all employees, Got Fuse Fireworks; Yelm Christen Church and all emplyees; Term: February 15, 2015 through February 14, 2016 The Certificate Holder and the above listed are Additional Insureds with respects to General Liability policy as required by written contact. CERTIFICATE HOLDER CANCELLATION © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Yelm ACCORDANCE WITH THE POLICY PROVISIONS. 105 W. Yelm Ave. Yelm WA 98597 AUTHORIZED REPRESENTATIVE © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD KEN KERSEY GOT FUSE FIREWORKS (253)208 -0489 PHONE (360)458 -3686 FAX LEASE AGREEMENT Thi "reement made and entered into this day referred to as the LESSOR and Ken Kersey, hereinafter referred to as LESSEE. by and between hereinafter LESSOR, in consideration of the covena nts and agreements hereafter made by LESSEE on the following a described real estate located at �6 2—,e /�' .57% .CA W for the purpose of selling and distributing fireworks for the perio hrougha&W LESSEE agrees to the following: 1. To pay LESSOR a non - refundable rent on the described premises for the agreed period in the sum of $1��- D. 2. LESSEE will operate his business on the leased premises in a lawful manner and in full compliance with applicable laws and regulations. Any and /or all non - compliance issues with the City, County and or State will the full legal responsibility of LESSEE. 3. LESSEE agrees to remove all trash, debris and equipment from LESSOR premises and leave premises in the same condition as was prior to lease period. No holes in the blacktop. 4. LESSEE will provide a certificate of Insurance to LESSOR on or before 0=/�nd will name described premises and LESSOR as additional insured. 5. The lease will be binding on LESSEE provided all permits and licenses are granted to the LESSEE by the county, city and state. LESSEE is hereby granted right of first refusal at this location for the same purpose and period for the next 3 years, followi the expiration of this lease. Date: 6 /T///-f LESSOR- AGENT /OW LESSEE -KEN KERSEY, Got Fuse Fireworks ;awl 01 JA, � S L o�.S m