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20160246 Permit Pkg 06072016City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: JESUS NAME PENTECOSTAL Address: 2120 MULWAUKEE WAY TACOMA WA 98421 Property Information: Site Address: 171nn RR s;n7 RF Assessor Parcel No.: 64303101001 Subdivision: Contractor Information: Name: AMERICAN PROMOTIONAL EVENTS NW Address: 2120 MULWAUKEE WAY TACOMA WA 98421 Contractor License No.: Permit No.: 20160246 Issue Date: 6/0712016 (Work must be completed within 180 days) Phone: 253 - 922 -0800 Owner: WALMART #3705 Lot: Phone: Expires: 0 /00 /0000 Project Information: Project: FIRE WORKS Description of Work: FIREWORKS STAND - WALMART PARKING LOT. Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item Contractor FIRE AMERICAN PROMOTIONAL EVENTS NW TOTAL FEES: ApplicaOt's Affidavit: I certify hat I have read and examined the information contained within the application and know the same to be tr a and c ct. I also certify that the proposed structure is in conformity with all applicable City of Yelm r a ions including those governing zoning and land subdivision, and in addition, all covenants, easements an restrictions of record. If applying as a contractor, I further certify that I am currently registered in t1d State of Washington. , Date Lo 1 Firm Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: City of Mm (36 } 458 -3244 REC #: 00233475 6/07/2016 3:42 PM OPER: CO TERM: 001 REF #: 30042477 PAID BY: TRAN: 33.0000 BUILDING PERMITS 20160246 30.OGCR JESUS NAME PENTECOSIAL 17100 SR 507 SE FIRE • 30.000R TENDERED: 30.00 CHECK APPLIED: 30.00- CHANGE: 0.00 4et" FIRE PROTECTION BUREAU FIREWORKS LICENSING PROGRAM PO Box 42600 Olympia WA 98504 -2600 (360) 596 -3914 FAX: (360) 596 -3934 APPLICATION FOR RETAIL FIREWORKS STAND PERMIT W WT7150 TO Governing body of city, town, or county in which DATE OF fireworks stand will be located. APPLICATION MAY 31, 2016 Applicant Name Address, City, State JESUS NAME PENTECOSTAL CHURCH 2120 MILWAUKEE WAY, TACOMA, WA. 98421 Sponsor (If other than applicant) Address, City, State GREG MATTOCKS 2120 MILWAUKEE WAY, TACOMA, WA 98421 Location of proposed fireworks stand lEnclose drawing of stand location) 17100 SR 507 SE, YELM WA WALMART #3705 Manner and place of storage prior, during, and after sales dates ON SITE WITH SECURITY State - Licensed Fireworks Supplier AMERICAN PROMOTIONAL EVENTS NW 2120 MILWAUKEE WAY, TACOMA, WA. 98421 FIREWORKS STAND PERMIT For the Fireworks Sales Year of 2016 (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 CITY OF YELM 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: From: To: Sponsor Location Sales for July 4th GREG MATTOCKS 17100 SR 507 S From: To: lsl Signature of Official Granting Permit Title3O�Ng V %gency Sales for December 31st Date Permit Number Zol (o Licensee Name JESUS NAME PENTECOSTAL CHURCH 3000 - 420 -013 (R 7/09) License Number 16 -0450 GREG MATTOCKS Pill i;fr4 .. �VVashington State Patrol Fire Protection Burea Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES STAND Lli �F'M4RSMAL'SCF °�`� Stand Number: SN -10544 Licensee Data American Promotional Events, Inc. 2120 Milwaukee Way Tacoma, WA 98421 License Number: WSPFL -02766 Phone Number: (253) 922 -080Q. Operational Data Wholesaler- TNT Fireworks'' County of Operation: Thurston Operates For'. Jesus Name Pe Stand Operated By' Greg Mattocks Date of Issue:April 1, 2016 Date of Expiration: January 31, 201 Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Yea 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 LIGELMS - EQ11TWhi � r� nAnogn!! R T APPLICATI- N;;;,_ ACORO® CERTIFICATE OF LIABILITY INSURANCE 11/1/2016 DATE(MM/DD/YYYY) 5/31/2016 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 Lockton Companies 3280 Peachtree Road NE, Suite #250 Atlanta GA 30305 (404) 460 -3600 NAME: CONTACT AX PHONE FA/C No): E -MAIL ADDRESS: N SI8GL00242 -151 11/1/2015 INSURER (S) AFFORDING COVERAGE NAIC # INSURER A: Everest Indemnity Insurance Company 10851 DAMAGES( RENTED PREMISES Ea occurrence ) INSURED American Promotional Events, Inc. 1359629 DBA TNT Fireworks, Inc. INSURER B: MED EXP (Any one person) INSURER C: INSURER 0: $ 1,000,000 P.O. BOX 1318 4511 Helton Drive Florence AL 35630 INSURER E : $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 INSURER F COVERAC % §' r'" CERTIFICATE NUMBER: 12934924 REVISION NUMBER: XXXXXXX 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 SUBR POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [A] OCCUR Y N SI8GL00242 -151 11/1/2015 11/1/2016 EACH OCCURRENCE $ 1 000 000 DAMAGES( RENTED PREMISES Ea occurrence ) $ 500 000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ] JET N LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL AUTOS OWNED SCHEDULED NON -OWNED HIRED AUTOS AUTOS NOT APPLICABLE COMBINED INGLE LIMIT Ea accident S $ XXXXXXX BODILY INJURY (Per person) $ XXXXXXX BODILY INJURY (Per accident) $ XXXXXX X PROPERTY DAMAGE Per accident $ XXXXXXX $XXXXXXX UMBRELLA LIAB EXCESS LIAB HCLAIMS-MADE OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX AGGREGATE $ XXXXXXX DED I RETENTION $ $ XXXYXXX WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-1 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA NOT APPLICABLE PER STATUTE ER OE RT E.L. EACH ACCIDENT $ XXX)D= E.L. DISEASE - EA EMPLOYEE $ XXXXXXX E.L. DISEASE -POLICY LIMIT 1 $ XXXXXXX DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TBRM(S) REFERENCED. PROPERTY LOCATED AT WALMART 17100 SR 507 SE YELM WA (WWT7150) Certificate holder is an additional insured on the General Liability as required by written contract subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION 12934924 CITY OF YELM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE YELM JESUS NAME PENTECOSTAL CHURCH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO BOX 749 ACCORDANCE WITH THE POLICY PROVISIONS. YELM WA 98597 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Walmart Tenant Access Letter TNT Fireworks to scope parking lot space and sell fireworks To: American Promotional Events, Inc. D.B.A. TNT Fireworks From Walmart Services Date: 12/21/15 RE: TNT Fireworks to scope parking lot space and sell fireworks Dear Valued Tenant, Thank you for your continued support and collaboration. Upon arrival at the store where the event/promotion will occur, this access Letter ( "Letter ") should be provided to store management. This letter shall serve as proof that you are authorized to enter the store and complete the parking lot scoping and execution of a temporary firework stand as a promotion /event for the time period specified below. You are also authorized and required to obtain the proper permitting as required by the local city, county, and /or state. Only your employees (collectively "Representatives ") may perform the promotion on your behalf. Your Representatives must produce credentials to store management showing that the Representative has been authorized by you to perform the promotion on your behalf. Project Timeline: Scope work and parking lot sales may happen anytime from February 01, 2016 — July 31, 2016 Store Associate (Management) Responsibilities: 1) Allow and agree upon space with TNT Fireworks to sell fireworks on the parking lot during the Independence Day season 2) Customers and employees of TNT Fireworks may have access to restrooms in Walmart facilities 3) For other questions call Walmart Field Support at 1- 700 - Walmart 4) Keep a copy of this LOA for your records This particular program does NOT violate the Walmart Corporate Solicitation Policy. Best regards, tj./ e Danielson Manager II, WM Services Ga Wi r Senior 'rector, Walmart Services SITE DIAGRAM ite Drawn: March 17, 2008 Address: —_ 17100 State Route 507 SE Store /Center: Wal -Mart Superstore City & State: Yelm, Washington Ncoca Cross Streets: LL yL C O Light House Light GPS Co- ordinates 46.56.003 N 122.37.725 W Entrance Im c_ a —� Q1 C Y nom. _c Loc No: WWT -7150 Ordinance of: City of Yelm Parcel No: Tent Faces Direction of: Open To The North Tent Size: 20 x 40 Notes: DO NOT STAKE TENT - WATER BARRELS OR CEMENT BLOCKS ONLY Tire & Lube Grocery Main Entrance Garden Center Wal -Mart ia0'+ cartl 63' 40' 1 E �' i• Trellis Gass -------------------------------------- - - - - -- i;k'm HWY 507 Open Field W r�4 a� D 0 TNT 40 X 20 Tent Layout 7 1 6* 1 Exit 56" m NO 402OTentlayout03 = 8' Table * -1 = 6' Table (& =Fire Extinguisher %Ltrtffirate of REGISTERED ISSUED BY: Date treated or APPUCAPON AZTEC TENTS manufactured CONCERN NO. 490 ALASKA AVENUE 0512006 TORRANCE, CA 90503 CAL COM13 F-41-9.01 �zz (310)328-5060 This Is to Certify that the materials described below hereof have been flame retardant treated (or are inher- ently nonflammable), FOR ABC PARTY RENTALS ADDRESS 4333 HARBOUR POINTE BLVD. SW CITY MUKILTEO STATE INA, 98275 Date ate "r� 0512 Certirication is hereby made tiTat., (Check "a" or "bIq (a) The articles described below this certificate have been treated with a flame retardant chemical approved and registered by the State Fire Marshal and that the application of said chemical was done in confor- L__j mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal. ail Name of chemical used ............ ...................... Chem. Reg. No. ........ ............... Meathodof application ........................... ................ ............... ........................ (b) The articles described below hereof are made from a flame-resistant fabric or material registered and iil'i approved by the State Fire Marshal for such use, Fabric has been tested and passes NFPA701-96 Trade name of flame-resistant fabric or material Ured.. LaminaledFabrk Reg. No. The Flame Retardant Process Used ,MY-.AQT.... Be Removed by Washing (will or will not) David Bradley Chuck Miller - President Name ofAppWcat& w Pro*jdion Superintendent ilia CUSTOMER ORDER NO. R160322 ITEMS MANUFACTURED: 2- 40'x40 - (2 PC.) JUA#BoTRA C Top ONLY ULTRA WHITE 3- 40 x20' JUMSOTRAC MIDDLE Top ONLY- ULTRA WHITE 2- 40'x10'JUXB0TRAC MIDDLE TOP OAtLY_ ULTRA WHITE 2- 30'x30'(2PC_) JUMBOTRAC Top ONLY- ULTRA WHITE 2- 30'X20'JUMBOTRA C MIDDLE TOP ONLY- ULTRA WHITE 2- 30'x10'JUMB0TRAC MIDDLE TOP ONLY- ULTRA WHITE 31- 10'x10'(1 PC.) FESTIVAL TOP ONLY- ULTRA mLilTE 8- 10 x20'(1 PC.) FESTIVAL TOP OArL Y_ uL TRA Wfq° 7-E 6-d zzz�C6V9zt sjejued ;UeA3 jeoedS oqV d80 C0 80 9Z unr