The URL can be used to link to this page

20150301 Permit Pkg 09152015City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: YELM COMMUNITY SCHOOLS Address: P.O. BOX 476 YELM WA 98597 Property Information: Site Address: 1315 YELM AVE W Permit No.: 20150301 Issue Date: 9/15/2015 (Work must be completed within 180 days) Owner: YELM COMMUNITY SCHOOLS Assessor Parcel No.: 21724210500 Subdivision: N/A Contractor Information: Name: ENTERTAINMENT FIREWORKS Phone: Address: P.O. BOX 7160 OLYMPIA WA 985197 Contractor License No.: Expires: 0 /00 /0000 Project Information: Project: FIRE WORKS Description of Work: HOMECOMING FIREWORKS DISPLAY OCTOBER 16, 2015 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item FIRE Contractor ENTERTAINMENT 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 a correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm regul do s inc those governing zoning and land subdivision, and in addition, all covenants, easement an resfriction of record. If applying as a contractor, I further certify that I am currently registered in t t to of ashingto Signature Date �— �S' S Firm -All d ,A, Nw 0w /-0 11 \M/ I /G Lot: N/A Fees $ 0.00 $ 0.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By 2co1SO3O1 CITY OF YELM COMMERCIAL BUILDING PERMIT APPLICATION FORM Project Address: 1315 Yelm Ave West, Yelm Parcel #: 21724210500 Zoning; Current Use: Proposed Use: New Construction ❑ Re -Model / Re -Roof / Tenant Improvement Plumbing ❑ Mechanical ❑ Fire Prevent/Suppress /Alarm F1 Other Project Description /Scope of Work: Display Fireworks for Homecoming Project Value: Building Area (sq. ft) Parking Garage 1s` Floor 2nd Floor 3`d 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 /TENANT NAME: Yelm High School ADDRESS 1315 Yelm Ave West EMAIL CITY Yelm STATE WA ZIP 98587 TELEPHONE 360- 458 -6210 ARCHITECT /ENGINEER LICENSE # ADDRESS EMAIL CITY STATE ZIP TELEPHONE GENERAL CONTRACTOR Entertainment Fireworks, Inc.TELEPHONE 360 - 352 -8911 ADDRESS PO Box 7160 EMAIL efi(a)pyrotech.com CITY Olympia STATE WA ZIP98507 -7160 FAX 360- 352 -0205 CONTRACTOR'S LICENSE # C -04085 EXP DATE CITY LICENSE # PLUMBING 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 JFC). 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 of Yelm. Applicant's Signature Date (/ Owner/ Contractor/ Owner's Agent/ Contractor's Agent/ Tenant (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 105 Yelm Avenue West (360) 458 -3835 PO Box 479 (360) 458 -3144 FAX Yelm, WA 98597 www.ci.yelm.wa.us THIS FORM IS 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 Event Date October 16, 2015 County Thurston Event Time Halftime Approx 8:00 ❑ AM ® PM Applicant's /Sponsor's Name Yelm High School Phone No. (360) 458 -6223 Pyrotechnic Operator Bradley Omon License No. P -04251 Experienced Assistant's Name Terri Schuette 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 or 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 discharged; the location of all buildings, highways, and other lines of communication; the lines 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 ll C �VYI Name of Permitting Official Title Phone No. atp n .�{s� • �3�4C�7 Permit Granted: FrYes w❑ Yes, with Restrictions (see "Notations" below) F-1 No Restrictions /Notations C-\.n. 2(:tS6315t Signature o Permitting Official Date of Approval 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 all applicable rules and ordinances pertaining to fireworks in this jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is responsible for any and all activities associated with the firing of this show. r F P 1 MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION 3000 -420 -050 (R 3/13) Please mail permit to EVENT DATE: October 16, 2015 Entertainment Fireworks, Inc. Post Office Box 7160 Olympia, WA 98507 -7160 (360) 352 -8911 Fax: (360) 352 -0205 License Number: C -04085 SPONSOR /NAME OF EVENT: Yelm High School Homecoming LOCATION OF DISPLAY: 1315 Yelm Ave. W, Yelm WA 98597 MANNER & PLACE OF STORAGE PRIOR TO DISPLAY (Subject to approval of Local Fire Authority) Delivered to site day of display. jvejtaih'i Klr 4LY THE BELOW LISTED PROI'' 7ESCRIF' IN ARE AUTHORIZED FOR THIS DISPLAY. Type of Fireworks 1.75" 1 AG Class "C" Roman Candle Batons I 11.75" Aerial Shells - 1 AG Class "C" I 11 AG Class "C" Multi -shot Cake Devices I TALL ITEMS ARE 1.4G CLASS "C" I Quantity 2 100 up to 50 SIGNATURE OF APPLICANT: 141.�' _ �" , Type of Fireworks Quantity I I. I I I I I I I. I of al �I �I a( US �I •Q I of c�a I i I i I I I I I I I I ( to M r i E to O t- U O O cu cu Cfl d >, L O ��1 � V O N r L? o fit C) C; M m i o �l o� v c ��M � o N to +, E cc ZQ O Q LL LL CD d o E r) o o C a w °i Cl) p 0. m O E M o °r o a LO N It O O O a. is C LO E OMB E LO ¢ � X Z d I I. I I I I I I I. I of al �I �I a( US �I •Q I of c�a I i I i I I I I I I I I ( C � d c Q 0 Q a ® v C Lr r K T- � ® ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD /YVYY) 8/27/2015 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 Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CONTACT NAME: Kristen Look PNONE 425- 586 -1016 FAX 425 451 -3716 E -MAIL INSURERS AFFORDING COVERAGE NAIC N INSURERAJ.H.E. Insurance Company 12866 15/2015 _ INSURED ENTEFIR -01 INSURER B: $1,000,000 INSURERC: CLAIMS -MADE X� OCCUR Entertainment Fireworks, Inc. 13313 Reeder Rd. SW ENTEFI R -01 INSURER D Tenino WA 98589 INSURERE: $100,000 INSURER F: -PREMISES MED EXP (Any one person) $5,000 COVFRAAFR CFRTIFICATF NIIMRFR• 1340531199 RFVIRION Nl)MRFR- 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 INSD WVD POLICY NUMBER POLICY EFF MM/D POLICY EXP MMID LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0103972 -01 15/2015 15/2016 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X� OCCUR DAMAGE TO RENTED (Ea occurrence ) $100,000 -PREMISES 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 ❑ PRO JECT F-] LOC PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY CPP0103972 -01 15/2015 15/2016 Ea accident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED X SCHEDULED AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per acc dent $ $ A UMBRELLA LIAB X OCCUR EPL0011552 -01 15/2015 1512016 EACH OCCURRENCE $1,000,000 X AGGREGATE $1,000,000 EXCESSLUIB CLAIMS -MADE DED X I RETENTION$0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER /EXECUTIVE STATUTE ERH E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if 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. 16, 2015. Location: Soccer Field next to Football Field. 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 ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 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 Yelm High School Yelm Community Schools ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 476 Yelm WA 98597 USA AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED — FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional 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 behalf 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. All other terms and conditions of the policy remain unchanged. CG133F(07/95)