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20160340 Permit Pkg 09292016City 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 Assessor Parcel No.: 21724210500 Subdivision: N/A Contractor Information: Permit No.: 20160340 Issue Date: 9/2912016 (Work must be completed within 180 days) Phone: 360- 458 -1900 Owner: YELM COMMUNITY SCHOOLS Name: ENTERTAINMENT FIREWORKS Phone: Address: PO BOX 7160 OLYMPIA WA 985077160 Contractor License No.: Expires: 0 /00 /0000 Project Information: Project: FIRE WORKS Description of Work: HOMECOMING FIREWORKS OCT 14 2016 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Lot: N/A Fees: Item Contractor Fees FIRE ENTERTAINMENT FIREWORKS $ 0.00 TOTAL FEES: $ 0.00 Applicant's Affidavit: certify that have read and examined the information contained within the application and know the same to be true d correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm reguihtiong including thos� governing zoning and land subdivision, and in addition, all covenants, easements and strictions of.record. If applying as a contractor, I further certify that I am currently registered in th�tipW of WSsJ i ton. A Firm OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: 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 Name of Event Yelm High School Homecom Street Address 1315 Yelm Ave. W City Yelm WA 98597 Applicant County Thurston Event Date October 14, 2016 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 Gary 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 e >ry C �'tZm Name of Permitting Official k0A." `E7rj Title _0 1 (_D/A)6 � F1 PC �lfFs�TV ��FIC,11(_ Phone No. 360 - `{SY -94017 Permit Granted: Yes ❑ Yes, with Restrictions (see "Notations" below) ❑ No Restrictions /Notations of Permiftinq Official 17- I, ate of Approval Z6110 0 34C) 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. MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION 3000 - 420 -050 (R 3113) Please mail permit to Entertainment Fireworks, Inc. �e�taihhi A Post Office Box 7160 Wr 0,1 IF Olympia, WA 98507 -7160 OV (360) 352 -8911 Fax: (360) 352 -0205 �'Y.prkg N EVENT DATE: October 14, 2016 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. ONI,v THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. Type of Fireworks 11.75" Aerial Shells - 1 AG Class "C" 11.4G Class "C" Multi -shot Cake Devices 100 up to 50 SIGNATURE OF APPLICANT: Quantity 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 n Fire Prevent/Suppress /Alarm ❑ Other Project Description /Scope of Work: Display Fireworks for Homecoming October 14 2016 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/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 efiCcDpyrotech.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 (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. Applicant's Signatur Owner / Contractor / � - .2 6 b Date 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 ACCO >RO® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 18/10/2016 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 endorsemen s . PRODUCER Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 NAMEACT Kristen Look PHONE 425 586 -1016 FAX 425 451 -3716 E -MAIL INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:T.H.E. Insurance Company 12866 2/15/2016 INSURED ENTEFIR -01 INSURER 0: $1,000,000 INSURERC: CLAIMS -MADE ❑ OCCUR Entertainment Fireworks, Inc. 13313 Reeder Rd. SW ENTEFIR -01 INSURER D: INSURER E: _ Tenino WA 98589 INSURER F $ COVERAGES CERTIFICATF NLIMRFR- 1003664768 RFVISION NIIMRFR- 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 USA R WV POLICY NUMBER POLICY EFF MMID POLICY EXP M LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0103972 -02 2/15/2016 2/1512017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ❑ OCCUR T RENTED PREMISE Ea occurrence $100,000 -PREMISES MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ GEN'L X POLICY ❑ PRO JECT �1 LOC PRODUCTS - COMP/OP AGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY CPP0103972 -02 2/15/2016 2/15 /2017 Ea accident IN LIMIT-- $1,000,000 BODILY INJURY (Per person) _ $ ANY AUTO ALL OWNED SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS Ix X PROPERTY DAMAGE Per accident $ E A UMBRELLA LIAR X OCCUR EPL0011552 -02 2/15 /2016 2/15/2017 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 PER OTH- STATUTE ER E.L EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYE — $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ 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. 14, 2016. 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 Yelm High School Yelm Community Schools SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 476 ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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