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20170239 Permit Pkg 06212017City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458-3144 Applicant: Name: YELM FFA ALUMNI Address: P.O. BOX 557 YELM WA 98597 Property Information: Site Address: 608 YELM AVE E Assessor Parcel No.: 64303700300 Contractor Information: Name: YELM FFA ALUMNI Address: JEANINE YODER P.O. BOX 557 YELM WA 98597 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.: 20170239 Issue Date: 6/21/2017 (Work must be completed within 180 days) Phone: 458 -5290 Owner: PRAIRIE PARK Subdivision: Lot: Phone: Expires: 0 /00 /0000 Heat Type (Electric, Gas, Other): Contractor YELM FFA ALUMNI TOTAL FEES: Applicant's ffidavit: I cert ify that have read and examined the information contained within the application and know the same to be true a d correct. I also certify that the proposed structure is in conformity with all applicable City of Ye lm regul tions includi hose governing zoning and land subdivision, and in addition, all covenants, easements nd ictions record. If appl ing as a contractor, I further certify that I am currently registered i th tate of W ingto Signature Date LA. Firm Id, 1,uA F17� Q AI( M.NA, Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: THIS FORM IS INTENDED FOR USE BY LOCAL AUTHORITIES HAVING JURISDICTION (AHJ) IN THE EVENT THEY DO NOT HAVE A PERMIT FORM SPECIFIC FOR RETAIL FIREWORKS SALES AT A CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY. IT IS NOT MEANT TO BE REQUIRED IN ADDITION TO OR IN LIEU OF ANY LOCAL PERMITTING FORM AND /OR PROCESS THAT MAY EXIST WITH THE LOCAL AHJ. Directions: Provided the local jurisdiction has no permit form of their own, complete this permit application and submit it with the local AHJ portion of your Retail Fireworks Stand License to the jurisdiction in which you wish to run your CFRS facility. WASHINGTON STATE FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New /First Time Applicant Previous Permit Holder Name of Group, Organization, or Person (Last, First, Middle Initial, and Date of Birth) Issued the Fireworks Retailer License Name of Permit Applicant (Last, First, Middle Initial, and Date of Birth) l; 20 ajt,� ' L".)A i Permit plicant Mailing Address (Complete Inclui ing Street, City, State, and ZIP Code) Phone Number E-MaIll Addtbss Local Business Number (if required) CFRS Facility Information OStand ❑ Tent Other: Size:` 3_ Specify Square FeettDimensions CFRS Facility Address (Complete Including Street, City, State, and ZIP Code) f'PAi -I tsar —k H%,�L iijgs` U-C Name of Property Owner Phone Number Parcel Number for Stand Location Fireworks Supplier Information List all of the licensed fireworks wholesalers who will be supplying this stand product Storage Information ❑ On Site ,Off Site: 2-07 >i S7- A�{ Storage Address (Complete Including Street, City, State, and ZIP Code) ❑ Sales Structure ❑ Detached Building ❑ Truck/Trailer ❑ Other: Specify CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines: ❑ Application /Permit Fee ❑ Insurance Certificate ($1,000,000) ❑ Clean -Up Bond Fee (if applicable) ❑ Valid Washington State Fireworks Retailer License ❑ Property Owners Written Permission ❑ Detailed Site Plan ❑ Interior Plan (required for tents and "other" facilities) I hereby certify the information in this application is true and correct. I am aware of and agree to comply with all relevant provisions of law, rule, and any ordinance of the state of Washington and the city /county permitting this CFRS Facility. Signature of Permit Applicant Printed Name of Permit Applicant I FIRE CODE AUTHORITY HAVING JURISDICTION ;APPROVED ❑ DENIED Date of Signature 2011 C) ng Permit Number —(7 Approved By Date df AporovIal SEE BA OF THIS FORM FOR ANY RESTRICTIONS, CONDITIONS, OR NOTATIONS ON THIS PERMIT THE FIREWORKS RETAILER LICENSE HOLDER (LICENSEE) SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEM BOTH AVAILABLE FOR INSPECTION AT ANY TIME THE STAND IS IN OPERATION 3000- 420 -013(R 11/16) Cit)� of Mm (36) 458 -3244 RECD: 00272908 6/21/2017 OPER: CO TERM: 001 REFS: 275 PAID BY: TRAM: 33.0000 20170239 YELM FFA 608 YELM FIRE 1 E:NDERED : APPLIED: CHANGE: 1:32 PM BUILDING PERMI13 30.0(CR ALUMNI AVE E 30.0(CR 30.00 (HECK. 30.00- :�aQ S%M, WASHINGT BUILDING PERMIT APPLICATION 90 7 043 C ❑ New Construction (SFR) ❑ Remodel ❑ Mechanical ❑ New Construction (Duplex) ❑ Addition ❑ Commercial ❑ New Construction (Multi - family) ❑ Reroof ❑ Tenant Improvement ❑ Manufactured Home Placement ❑ Plumbing ❑ Fire Permit Property Address: (C)? Yc L w,, AVE_. EA57- / &_w, L� �► ggS7L Tax parcel number. 3037�o ?or.� Subdivision: "e /6 RwK Lot No.: Project Description /Scope of Work: 12ETAtL SMND Project Value: Heat Source: ❑ Gas ❑ Electric ❑ Solar Plan No.: Bedrooms: Baths: Area 1st Floor: 2nd Floor: 3rd Floor: Garage: Basement: Carport: Covered Patio: Front Porch: Applicant: KA eT /k�LU �o-yJ0 Owner: Pez_& , F4 Alt 4^p,' Address: ' Y—V—e- 51IIcf-sT Address: 14 5 aow 9s -3 Y7 Telephone:3�tE, .;Z34 St('q Telephone: Email:c.��r(K -1 (r. ►.v� �, '�.C:�+. Email f w� �,,�� . Architect /Designer: General: Address: License No.: Telephone: Telephone: Email: Email: Plumber: Mechanical: �a Email: Email: JUN i r 20 License No.: License No.: BY .. By submitting this application to the City of Yelm, you affirm that all answers, statements, and information `.r contained in and submitted with this application are complete and accurate to the best of your knowledge and that you are the owner of the property or duly authorized by the owner to act on their behalf. Permission is granted to representatives of the City to enter upon and inspect the property as reasonably necessary to process the application. 9 PRARI E P A R KtA TO: City of Yelm RE: Use of 608 Yelm Ave E. for Firework Stand The Yelm FFA Alumni has been granted permission to use the property located at 608 Yelm Ave. E (formerly First Citizens Bank) to house and sell fireworks. I am the property manager and have owner consent for all decisions affecting this property. If you need further assistance please feel free to contact me at deniseh @prairiepark.com or 360- 458 -7550. Denise Hibbeln, Director of Administration YELM CINEMASI UPTOWN LOUNGEI PRAIRIE HOTEL Phone: 360 - 458 -7550 1 Fax: 360 - 458 -8545 PO Box 5210, Yelm, WA 98597 700 Prairie Park lane — PO Box 5210 Yelm, WA 98597 Ph: 360458 -7550 Fax: 360 -458 -8545 YeImCSPTOPTAI Non Profit Insurance Program CERTIFICATE OF COVERAGE Issue Date: 06/13/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONVERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF COVERAGE DOES NOT CONSTITUE 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 SUBROGRATION IS WAIVED, subject to the terms and conditions of the policy, certain coverage may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COMPANIES AFFORDING COVERAGE LIMITS GENERAL LIABILITY Clear Risk Solutions American Alternative Insurance Corporation, et al. 451 Diamond Drive Ephrata, WA 98823 AUTOMOBILE LIABILITY PER OCCURRENCE American Alternative Insurance Corporation, et al. PROPERTY INSURED PER MEMBER AGGREGATE Yelm Community Schools PTOs /PTAs American Alternative Insurance Corporation, et al. PO Box 476 MISCELLANEOUS PROFESSIONAL LIABILITY Yelm, WA 98597 Princeton Excess and Surplus Lines Insurance Company COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE COVERAGE PERIOD INDICATED, NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF 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. TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP DESCRIPTION LIMITS DATE DATE Yelm Fire Dept. GENERAL LIABILITY Yelm, WA 98579 COMMERCIAL GENERAL LIABILITY N1 -A2 -RL -0000013 -08 06/01/2017 06/01/2018 PER OCCURRENCE $1,000,000 OCCURRENCE FORM PER MEMBER AGGREGATE $3,000,000 INCLUDES STOP GAP PRODUCT -CO MP /OP $1,000,000 PERSONAL & ADV. INJURY $1,000,000 LIABILITY IS SUBJECTTO A $50,000 SIR PAYABLE FROM PROGRAM FUNDS ANNUAL POOL AGGREGATE $50,000,000 AUTOMOBILE LIABILITY ANY AUTO Nl -A2-RL -0000013 -08 06/01/2017 06/01/2018 COMBINED SINGLE LIMIT EXCLUDED LIABILITY IS SUBJECTTO A $50,000 SIR PAYABLE FROM PROGRAM FUNDS ANNUAL POOL AGGREGATE NONE PROPERTY N1 -A2-RL -0000013 -08 06/01/2017 06/01/2018 ALL RISK PER OCC EXCL EQ & FL $75,000,000 EARTHQUAKE PER OCC EXCLUDED FLOOD PER OCC EXCLUDED PROPERTY IS SUBJECTTO A $50,000 SIR PAYABLE FROM PROGRAM FUNDS ANNUAL POOL AGGREGATE NONE MISCELLANEOUS PROFESSIONAL LIABILITY N1 -A2-RL -0000013 -08 06/01/2017 06/01/2018 PER CLAIM EXCLUDED LIABILITY IS SUBJECTTO A $50,000 SIR PAYABLE FROM PROGRAM FUNDS ANNUAL POOL AGGREGATE $40,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / SPECIAL ITEMS Regarding use of premises located -608 Yelm Ave E, Yelm, WA. Yelm Fire Dept. is named as additional Insured regarding this use only and is subject to policy terms, conditions, and exclusions. Additional Insured endorsement attached. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLI CY PROVISIONS. CERTIFICATE HOLDER AUTHORIZED REPRESENTATIVE Yelm Fire Dept. PO Box 777 Yelm, WA 98579 3259969 AMERICAN ALTERNATIVE INSURANCE COMPANY ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION (GENERAL LIABILITY) Named Insured Non Profit Insurance Program NPIP Policy Number Endorsement Effective N 1 -12-RL -0000013 -08 6/1/2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY This endorsement modifies insurance provided under the following: GENERAL LIABILITY COVERAGE PART This endorsement changes the policy effective on the inception date of the policy unless another date is indicated above. Schedule Person or Organization (Additional Insured): As Per Schedule on file with Clear Risk Solutions, Underwriting Administrator Prairie Park Holdings LLC PO Box 5210 Yelm, WA 98597 Regarding use of premises located -608 Yelm Ave E, Yelm, WA. Prairie Park Holdings LLC is named as Additional Insured regarding this use only and is subject to policy terms, conditions, and exclusions. Additional Insured endorsement attached. A. With respects to the General Liability Coverage Part only, the definition of Insured in the Liability Conditions, Definitions and Exclusions section of this policy is amended to include as an Insured the Person or Organization shown in the above Schedule. Such Person or Organization is an Insured only with respect to liability for Bodily Injury, Property Damage, or Personal and Advertising Injury caused in whole or in part by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In performance of your ongoing operations; or 2. In connection with your premises owned or rented to you. B. The Li mits of Insurance applicable to the additional Insured are those specified in either the: 1. Written contract or written agreement; or 2. Declarations for this policy, whichever is less. These Limits of Insurance are inclusive and not in addition to the Limits Of Insurance shown in the Declarations. All other terms and conditions remain unchanged. Includes copyrighted material of the Insurance Services Office, Inc., with its permission. RL 2163 12/12 3259972 Page 1 of 1 ONevvrt 9Tgr6 Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE 'R44SNAVg Stand Number: SN -11530 Licensee Data Yelm FFA Alumni Association .O. Box 2088 Yelm, WA 98597 License Number: WSPFL -00480 Phone Number: (360) 239 -1214 , Operational Data Wholesaler: Thunder Fireworks County of Operation: Thurston Operated For: Licensee"" Stand Operated By: Kurt Klump Date of Issue-.April 28, 20T7 Date of Expiration: Jan uaty31, 210' Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years 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 only 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 FIREWQPM WHOLESALER Washington State Patrol Fire Protection Office of the State Fire Marshal; CONSUMER FIREWORKS RETAIL SALES (CFRSI F *4RSHAVS oE�4 Licensee Data Yelm FFA Alumni Association .O. Box 2088 Yelm, WA 98597 License Number: WSPFL -00480 hone Number: (360) 239 -121 Stand Number: SN -11530 Operational Wholesaler-.IM County of Operation: Thur Operated For: Lice Date of Issue -April 28, 2017 Date of Expiration- January 31, 2018 . Consumer Fireworks Retailer 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. THIS PORTION OF THE LICENSE MUST BE POSTED AT THE STAND AT ALL TIMES 7TF Washington State Patrol Fire Protection 0 Office of the State Fire Marshall CONSUMER FIREWORKS RETAIL SALES (CFRS) I Licensee Data �Yelm FFA Alumni Association P.O. Box 2088 Yelm, WA 98597 License Number: WSPFL -00480 Phone Number: (360) 239-1214J Stand Number: SN -115 Wholesaler: County of Operation: Thurston Operated For: Licensee Date of Issue-.April 28, 2017 Date of Expiration: January 31, 2018 Consumer Fireworks Retailer 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 ,. O�t / / 6 .ls""",� KIIIry6 IT- -To tpy- tJtz PL.P,w I D15PL6y 9Rcks I ExTi ►X-�U , StA L � ex rl 5 tj-.e S w,NO�w S