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20170237 Permit Pkg 06262017THIS 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 Got Fuse Fireworks/ Ken Kersey Name of Group, Organization, or Person (Last, First, Middle Initial, and Date of Birth) Issued the Fireworks Retailer License Ken Kersey Dec 24, 1955 Name of Permit Applicant (Last, First, Middle Initial, and Date of Birth) PO Box 1106, McKenna WA. 98558 Permit Applicant Mailing Address (Complete Including Street, City, State, and ZIP Code) (253- 208 -0489) cjkersey @ywave.com (253- 208 -0489) Phone Number E -Mail Address Local Business Number (if required) CFRS Facility Information ❑ Stand ® Tent Other: Size: goxgz) Specify Square Feet/Dimensions 16628 State Route 507, Yelm Wa. 98597 _ CFRS Facility Address (Complete Including Street, City, State, and ZIP Code) 'Gil Syr - u&" ir.S Name of Property Owner Phone Number Parcel Number for Stand Location Fireworks Supplier Information List all of the license. fireworks wholesalers who will be supplying this stand product Pacific Northwest Fireworks 7n�ju,tde� J=; few" ,pytc 1404 te wo 'growP7 Storage Information XOn Site ❑ Off Site: 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. , Ken Kersey 4 - Y ,9017 —� Si nature of FTrmit Applicant Printed Name of Permit Applicant Date of Signature I FIRE CODE AUTHORITY HAVING JURISDICTION ❑ APPROVED ❑ DENIED I n2-; ZI I Permit Number Approved By Date of Approval SEE BACK OF THIS FORM FOR ANY RESTRICTIONS, CONDITIONS, OR NOTATIONS ON THIS PERMIT ff- Signature of Permitting Official PkMd Printed Name an itle Dat Pof nature 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) City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: GOT FUSE FIREWORKS Address: PO BOX 1106 MCKENNA WA 98558 Property Information: Site Address: 16628 HWY 507 SE Assessor Parcel No.: 64303400501 Subdivision: Contractor Information: Name: GOT FUSE FIREWORKS Address: KEN KERSEY PO BOX 1106 MCKENNA WA 98558 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.: 20170237 Issue Date: 6/26/2017 (Work must be completed within 180 days) Phone: 2532080489 Owner: CHRISTENSENS Phone: Expires: 0 /00 /0000 Heat Type (Electric, Gas, Other): Contractor GOT FUSE FIREWORKS TOTAL FEES: Applica (at Affidavit: I certify t have read and examined the information contained within the application and know the same to be tr and correct. I al e i that the proposed structure is in conformity with all applicable City of Yelm re ulations in u g those g verning zoning and land subdivision, and in addition, all covenants, easemeits and re tricti ns of rec d. If applying as a ontractor, I further certify that I am currently registered in the ate o Was ing Signatures ,- Date - Firm "Ot t�up" Lot: Fees $ 30.00 $ 30.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: Cit�l of Yolm (36 ) 458 -3244 RECD: 00273122 6/26/2017 2:59 PM OPEF: CO TERM: 001 REFS: PAID BY: ALIC.IA TRAM: 33.0000 BUILDING PERMITS 20170237 30.O(CR GOT FUSE FIREWORKS 16628 HWY 507 SE FIRE 30.O(CR 1E:NDERED: 30.00 (ASH APPLIED: 30.00- CHANGE: 0.00 "I L _LJ J, Li 'J 1ASHINCTO IN110--q'i, BUILDING PERMIT APPLICATION av 17 0 a3 ❑ 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: /0^0 40 6�� ' Tax parcel number:i f-d a � • -:;7s CAS a A4 M "-I" w ' �' CERTIFICATE OF LIABILITY INSURANCE lit. M /DD YYYY) TYPE OF INSURANCE 9 7 6/9/201/201 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 CONTACT Britton Gallagher One Cleveland Center, Floor 30 1375 East 9th Street Cleveland OH 44114 NAME: PHONE FAX -7101 _ -6 A/C No : - ADDRESS, _ INSURERS AFFORDING COVERAGE NAIC M INSURER A - INSURED 2567 Jake's Fireworks Inc. 1500 E 27th Terr. INSURER B Everest Indemnity n ur 1 _ INSURER C: INSURER D MED EXP (Any one person) Pittsburg KS 66762 INSURER E: CLAIMS -MADE O OCCUR INSURER F 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 NSR SUBR WVD POLICY NUMBER POLEFF MM DI DYIYYYY MM/DDY/YYYY LIMITS B GENERAL LIABILITY X ' COMMERCIAL GENERAL LIABILITY S18GL00320 -171 2/15/2017 2/15/2018 EACH OCCURRENCE $1,000,000 AMAGE TO RENTED PREMISES Ea occurre ncel $500,000 MED EXP (Any one person) $ CLAIMS -MADE O OCCUR PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 1 PRO- iX LOC PRODUCTS - COMP /OP AGG $2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMI I Ea accident $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS 'HIRED AUTOS NON OW AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per accident) _. $ PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAB IXCESS LIAB X OCCUR CLAIMS -MADE FXC6018367 2 11512017 2/15/2018 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED RETENTION $ WC STATU- OTH- - WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER]EXECUTIVE OFFICERJMEMBER EXCLUDED? ❑ (Mandatory in NH) NIA E.L. EAC $ 7ACCIDENT E.L. DISEEMPLOYE - $ If yes, describe under DESCRIPTION OF OPERATIONS below E, L. DISEA- LICY LIMIT $ FAddi'tional TION OF OPERATIONS i LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 11 more space Is required) Insured extension Of coverage is provided by above referenced General Liability policy where required by written agreement. Location: 16628 State Route 507 SE, Yelm, WA 98597; Owner: Tim Bauguts; ersey, P.O Box 1106, McKenna, WA 98558; f Yelm, 105 W. Yelm Ave., Yelm, WA 98597; February 15, 2017 through February 14, 2018; The Certificate Holder and the above listed are Additional Insureds with respects to General Liability policy as required by written contract. FICATE HOLDER CANCELLAT 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 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD GOT FUSE FIREWORKS (253)208 -0489 PHONE EMAIL: cjkersey @ywave.com LEASE AGREEMENT This agreement made and entered into this 8th day of June, 2017 by and between Christensen's Home Furniture Company, 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 507 SE, Yelm WA. 98597. For the purpose of selling and distributing fireworks for the period of June 26`h, 2017 through July 6`h, 2017. LESSEE agrees to the following: 1. To pay LESSOR a non - refundable rent on the described premises for the agreed period in the sum of $ '' 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 June 101h, 2017 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. CL LESSOR - AGENT /OWNER OF Christensen's Home Furniture Company LESSEE -KEN KERSEY, Got Fuse Fireworks j- CITY OF YELM BUSINESS ]LICENSE IS HEREBY LICENSED TO OPERATE GOT FUSE FIREWORKS PO BOX 1106 MCKENNA WA 98558 This License must be sted in a conspicuous place at the location. LICENSE TYPE OF LICENSE Retail 2017 LICENSING PERIOD JAN. 1, 2017 OR FROM TO DEC. 31, 17-10283 LICENSE NUMBER AMOUNT $ DATE PAID sy: NOTTRANSFERABLE APPLICANT'S RECEIPT Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal } CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE 17 -0585 'yAR3XAl' Licensee Data Got Fuse Fireworks P.O. Box 1106 McKenna, WA 98558 License Number: WSPFL -02065 ;?hone Number: (253) 208 -0489 Stand Number: SN -11550 Operational Data Wholesaler: R. Brown County of Operation: Thurston Operated For: Licensee Stand Operated By: Jake Kilton Date of Issue:May 1, 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 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 FIREWORKS WHOLESALER Wasnington state Patrol II-ire rroiecuon bureau Office of the State Fire Marshal CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE MgRSNAt'S�'�`V Licensee Data Got Fuse Fireworks P.O. Box 1106 r cKenna, WA 98558 cense Number: WSPFL -02065 hone Number: (253) 208-0484 Stand Number: SN -11550 ational Data .u,. Wholesaler: R. B County of Operation: Thursto Operated For: License Stand Operated By: Jake Ki 17 -0585 Date of Issue:May 1, 2017 Date of Expiration January 31, zul is 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 location /stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesale THIS PORTION OF THE LICENSE MUST BE POSTED AT THE STAND AT ALL TIMES Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal` CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE 104" Stand Number: SN -1155 Licensee Data mot Fuse Fireworks P.O. Box 1106 �uMCKenna, WA 98558 License Number: WSPFL -02065 ,Phone Number: (253) 208 -0489 Wholesaler: R. r County of Operation: Thurston Operated For: Licensee Stand, Operated By: Jake Kilto Date of Issue:May 1, 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_. -,. -.n ;,