Loading...
20170316 Permit Pkg 09202017City 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 Contractor Information: Name: ENTERTAINMENT FIREWORKS Address: PO BOX 7160 OLYMPIA WA 985077160 Subdivision: N/A Permit No.: 20170316 Issue Date: 9/20/2017 (Work must be completed within 180 days) Phone: 360- 458 -1900 Owner: YELM HIGH SCHOOL Phone: Project Information: Project: FIRE WORKS Description of Work: DISPLAY FIREWORKS FOR HOMECOMING ON SEPT 29, 2017 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item FIRE Contractor ENTERTAINMENT FIREWORKS TOTAL FEES: r Applicants Affidavit: certify that I have read and examined the information contained within the application and know the same to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of Yelm reg4lati those governing zoning and land subdivision, and in addition, all covenants, easement's an restriction of record. If applying as a contractor, I further certify that I am currently registered�, in tate o ashington. Signature Date — 1 Firm �j�.(p v ,1 Vl WtD� �i0 .(ts7s li IL S Lot: N/A Fees $ 0.00 $ 0.00 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 Hiqh School Homecomin Street Address 1315 Yelm Ave. W City Yelm WA 98597 County Applicant Thurston Event Date September 29, 2017 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 Name of Permitting Official�,(1y p� Title YY� k C�tNC�nV��� }� Phone No. (4 SP, - 383S Permit Granted: es ❑ Yes, with Restrictions (see "Notations" below) ❑ No Restrictions /Notations rmitting ZO 17 p 31(x_ Date f A royal 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 3/13) V� 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 Fire Prevent/Suppress /Alarm Other Project Description /Scope of Work: Display Fireworks for Homecoming on September 29, 2017 Project Value: Building Area (sq. ft) Parking Garage 1St Floor 2nd Floor 3`d 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 Copy of City Mitigation documentation JFC). 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. Q 7 wt , / / Applicant's Signature_ Date Owner / Contractor j Owner's Agent /)Contractor's 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 D80days� (C 5EP 0 7 20 i l 105 Yelm Avenue West (360) 4554&3&---------- -- - - -- - -- PO Box 479 (360) 458 -3144 FAX Yelm, WA 98597 www.ci.yelin.wa.us Please nail permit to EVENT DATE: September 29, 2017 Entertainment Fireworks, Inc. Post Office Box 7160 Olympia, WA 98507 -7160 (360) 352 -8911 Fax: (360) 352 -0205 License Number: C -04085 SPONSOR /NAME OF EVENT: Yelm High School Homecoming F orks 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. ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. Type of Fireworks 11.75" Aerial Shells - 1.4G Class "C" I 11 AG Class "C" Multi -shot Cake Devices I Quantity 100 up to 50 SIGNATURE OF APPLICANT: Type of Fireworks Quantity ��N�NCroNSrr� �'9F'MARSHAVS _icensee Data Bradley R. Omon P.O. Box 5753 Lacey, WA 98509 License Number: P -04251 ✓Z1 State Fire Mar I Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License 17 -1356 Phone Number: (360) 970 -5524 Email Address: brad _pyro81 @yahoo.com Date of Issue: January 30, 2017 Date of Expiration: January 31, 2018 Licensee Signature Licensee Wall Mount Card — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — ��N�NGTOR8r4TF ;J RSNAVS OEF\ Licensee Data Bradley R. Omon -1.0. Box 5753 Lacey, WA 98509 License Number: P -04251 Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License , L11- - State Fire Mar Ij 17 -1356 Phone Number: (360) 970 -5524 Email Address: brad_pyro81 @yahoo.com Date of Issue: January 30, 2017 Date of Expiration: January 31, 2018 Licensee Signature General Display Employer Portion — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — --------- 1) Cut along dotted lines to release the four license cards. 2) All four license cards are individually legal and valid evidence of licensing. 3) All four cards constitute an entire license for a single operator. 4) The Licensee must sign all four portions of the license. 5) ALL four license cards are legal and valid evidence of licensing. 6) The Licensee must carry either the wallet (landscape) or the lanyard card (portrait). License Number: P -04251 Pyrotechnic Operator License E Washington State Patrol 17_1356 =ire Protection Bureau January 31, 2018 Bradley R. Omon CurrentlValid Until Pyrotechpic Operator 7L 7 State Fire Ma al 7 Licensee Signature ------ - - - - -- ------ 17-1356 License Number: P -04251 Washington State Patrol Fire Protection Bureau Pyrotechnic Operator Licensing Type January 31, 2018 Current and Valid Until Bradley R. Omon Pyrotechnic Operator Licensee Si nature State Fire Mar�X( l 0 0 s V s a,o L' 0q.. ACORD® CERTIFICATE OF LIABILITY INSURANCE �i DATE,MMIDD/YYYY) 8/29/2017 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 Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CONTACT NAME: Kristen Look PH . 425 -586 -1016 FAX DNE No : 425 -451 -3716 E-MAIL INSURERS AFFORDING COVERAGE NAIC # INSURERA:T.H.E. Insurance Company 12866 2/15/2017 INSURED E N TE F I R -01 INSURER B: $1,000,000 INSURER C: CLAIMS -MADE IX OCCUR Entertainment Fireworks, Inc. 13313 Reeder Rd. SW ENTEFIR -01 INSURER D: INSURER E: $100,D00 Tenino WA 98589 INSURER F: $ COVERAGES CERTIFICATE NUMBER: 1486162047 REVISION NUMBER: 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 INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CPP0103972 -03 2/15/2017 2/15/2018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE IX OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $100,D00 MED EXP (Any one person) $ PERSONAL BADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY ❑ PRO- JECT LOC ❑ X PRODUCTS - COMP /OP AGG $2,000,000 $ OTHER: A AUTOMOBILE LIABILITY ABILITY CPP0103972 -03 2/15/2017 2/15/2018 SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO AUT OWNED X SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS X NON -OWNED X IAUTOS PROPERTY DAMAGE Per accident $ A UMBRELLA LIAB X OCCUR EPLOO12101 -01 2/15/2017 2/15/2018 EACH OCCURRENCE $1,000,000 X AGGREGATE $1,000,000 EXCESS LIAB CLAIMS -MADE DED X RETENTION$O $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N I PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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: Sept. 29, 2017. 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 ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yelm High School Yelm Community Schools 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