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20160255 Permit Pkg 06222016City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: KEN KERSEY Address: PO BOX 1106 MCKENNA WA 98558 Property Information: Site Address: 16628 HWY 507 SE Permit No.: 20160255 Issue Date: 6/22/2016 (Work must be completed within 180 days) Phone: 253 - 208 -8489 Owner: CHRISTENSENS HOME FURNISHING Assessor Parcel No.: 64303400501 Subdivision: Contractor Information: Name: KEN KERSEY Phone: Address: KEN KERSEY PO BOX 1106 MCKENNA WA 98558 Contractor License No.: Expires: 0 /00 /0000 Project Information: Project: FIRE WORKS Description of Work: FIREWORKS STAND. JUNE 26 THRU JULY 6, 2016 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item FIRE Contractor KEN KERSEY TOTAL FEES: Applicant' Affidavit: I certify tha I have read and examined the information contained within the application and know the same to be true a id correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm regul tions including those governing zoning and land subdivision, and in addition, all covenants, easements and rosuiction s. f record. If applying as a contractor, I further certify that I am currently registered i the ate of Wa ington. Signature Date (C • ZZ" Firm Y0,✓) I� �/ 'V.;,p I J Lot: Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: Cite of Mm (361) 458 -3244 RECD`: 00235368 6/22/2016 1:08 PM OPER: CO TERM: 001 REFA' : 148 PAID BY: TRAM: 33.0000 BUILDING PERMITS 20160255 30.000R KERSEY, KEN 16628 HWY 501 SE FIRE 30.000R 1ENDERED: 30.00 CHECK APPLIED: 30.00- CHANGE: __� 0.00 + "NG1GTGA,,,,OfF FIRE PROTECTION. BUREAU FIREWORKS LICENSING PROGRAM PO Box 42600 ❑o © ®® WASHINGTON STATE PATROL Olympia WA 98504 -2600 9ENMSNA0 GF (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 Applicant Name Address, City, State /� C G G r-SR f01 Fug ff l ' iew-,* ��, BoX 1106 p p cj iln� /�SSO Sponsor (If othe than applicant) Address, City, State rooposed fireworks stand [Enclose drawing of stand location] Locati on o//�O f p� '1 146& c5-o d m 4, / (J`� 7 Manner and place of storage prior, during, and after sales dates / 141 / codac� red/ � eid �urre(� v State - Licensed Fireworks Supplier �CtCii e dflv�$%� ! i`te 1�1/df�s FIREWORKS STAND PERMIT For the Fireworks Sales Year of- a016 (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 C;�y err ycb., 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: Ti.A'd :7--? J X016 From: To: ;r,4)y y 7-11— 'Zc2 /6 To: Sponsor 4,4my .- co f F'15C F' &- W4 fk5 Location ��lo�� f}G�t' r 6'07 -1-F /s/ /s/ i7/�G�.�� Signature o cial Granting Permit Signature of Applicant Title �A. w CC-0— Agency f,� '0/ Date 46-gg -16 Permit Number Licensee Name ken )�ea eV �'�f �x iChv License Number 3000420 -013 (A 3/09) CITY OF YELM COMMERCIAL BUILDING PERMIT APPLICATION FORM Project Address: %16,6 Ak rt 607 Parcel #: Zoning; Current Use: do&o zss- Proposed Use: TiV Ti / --Al New Construction ❑ Re -Model / Re -Roof / Tenant Improvement Plumbing �i Mechanical Fire Prevent/Suppress /Alarm X Other Project Description /Scope of Work: Project Value: Building Area (sq. ft) Parking Garage 1s` Floor 2nd Floor 3rd Floor Building Height Are there any environmentally sensitive areas located on the parcel? /VO If yes, a completed environmental checklist must accompany permit application. BUILDING OWNER/TENANT NAME: %eq e ADDRESS EMAIL CITY STATE ZIP TELEPHONE 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 # 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 (TFC). 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. ApaRcant's Signature Owner Contractor / Owner's Agent / Contractor's Agent / 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 105 Yelm Ave W Yelm, WA 98597 � (?*S-p gv (360) 458 -3835 (360) 458 -3144 FAX - tvZ(ffirn.yPwat a. us *0N\NGTON $,,, F *OSHAO OEF\44. Washington State Patrol Fire ttoff BU r Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES STAND LIC Licensee Data Kenneth Kersey PO Box 1106 McKenna, WA 98558 License Number: WSPFL -02827 Phone Number: (253) 208 -0489 Stand Number: SN -10778 Operational Data Wholesaler: Pacific Northwest FW County of Operation: Thurston Operated For: Licensee Stand Operated By: Kenneth Ke Date of Issue -April 29, 2016 Da xprra lon anuary 201' Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Years 5a This license is NOT valid without a permit from a local fire code official /authority having jurisdiction. This license allows for operation of a retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler, THIS LICENSE PORTION ACCOMPANIES YOUR LOCAJ P_FRnntr nooi icnTanu KEN KERSEY (253)208 -0489 PHONE (360)458 -3686 FAX LEASE AGREEMENT This agreement made and entered into this day: by and between p,`� gserl5 D.M� �rg�s )nom_, hereinafter referred to as the LESSOR and Ken Kersey, hereinafter referred to as LESSEE. LESSOR, in consideration of the covenants and agreements hereafter made by LESSEE on the following described real estate located at 16628 State Route 507 SE, Yelm Wa. 98597. For the purpose of selling and distributing fireworks for the period through LESSEE agrees to the following: 1. To pay LESSOR a non - refundable rent on the described premises for the agreed period in the sum $1500.00 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 the date lease is signed, and will name described premises and LESSOR as additional insured. LESSEE is hereby granted right of first refusal at this location for the same purpose and period for the next 3 years, following the expiration of this lease. Date: -ep, -,:?g -/6 LESSOR -AGEN OWN LESSEE -KEN KERSEY, GOT FUSE FIREWORKS BILITY INSURANCE =DAffy" f AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES rE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED z'licy(ies) must be endorsed. H SUBROGATION IS WANED, subject to Tdorsement. A statement on this Certificate does not confer rights to the CONTACT NAME: LAICTN Fn.-216-6-58-71 00 AIC No : - 65� -7i Q ::AIL RES • INSURER(S) AFFORDING COVERAGE NAIC 2 INSURER A:Maxum Indemndy Company 26743 INSURER B :Everest Indemnl Insurance Co. 10851 INSURER C: 2/15/2016 INSURER D: �_tOA_IMAG5 H OCCURRENCE RENTED5500 EMI S Ea xanEnce INSURER E : MEDEXP one parson INSURER F: RFVISIAN NI WIRER- 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 TR TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN {. BR -j POLICY NUMBER POLICY EFF POLICY EXP rM LIMITS B GENERAL LIABILITY X� COMMERCIAL GENERAL LIABILITY SIBGL00320- 161 2/15/2016 2/15/2017 �_tOA_IMAG5 H OCCURRENCE RENTED5500 EMI S Ea xanEnce S1,000,000 000 MEDEXP one parson : $ _J CLAIMS -MADE OCCUR PERSONAL & ADV INJURY _ $1 000,000 - GENERAL AGGREGATE 52,000,000 __ _ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS - COMP/OP AGG 32,000,ODO I $ POLICY X LOC 0 I AUTOMOBILE LIABILITY Ea a acatlentl SINGLE LIMIT S P ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS I_. SCHEDULED TO LED BODILY INJURY (Per accident) S HIRED AUTOS Ir AU—OWNED TO 111 PROPERTY DAMAGE acadent Z $ A UMBRELLA LIAR X JOCCUR EXC6018367 2/15/2016 2/15/2017 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 X EXCESS LIAB , CLAIMS-MADE DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS' LJASIUTY YIN ANY PROPRIETORIPARTNELRIEXECUTWE OFFICERIMEMBER EXCUDED9 ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA VrIC STATU- OTW E.L_EACH ACCIDENT -- S E.L. DISEASE - EA EMPLOYE $ E_L DISEASE - POLICY LIMIT S i DESCRIPTION OF OPERATIONS / LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required( Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. Sales Location: 16628 State Route 507 SE, Yelm, WA 98597; Land Owner: Christensen's Home Furnishings; Christensen's Home Furnishings and all its employees, City of Yelm and all it's employees, Yelm Christian Center and all it's employees; Ken Kersey Term: February 15, 2016 through February 14, 2017 The Certificate Holder and the above listed are Additional Insureds with respects to General Liability policy as required by written contract. City of Yelm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 105 W. Yelm Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Yelm WA 98597 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tO Tytlll -ZUTU ACURU CORPORATION. All rights reserved. ACORn 2.1; r)ninmsi 'M- A ^— - - -- -- "� el�S eriS ark �'� u(-n4iu m df ' vc � e n V r* 4 ce h a h i r -,s 1 1 i