HomeMy WebLinkAboutFIR2004-00014 Fireworks Stand - FIR Application - 3/5/2004 111 ��I�I�rll\ Ir1�lO �l.
Mason County
Fireworks Permit Application
PO BOX 186 Permit# FIR Qp
426 W Cedar St
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E D Shelton WA 98584 Receipt # S1 ZL-D4
(360) 427-9670 ext 273
MAR 0 5 2004 CK #
426 W: CEDAR STz Date Received 3- -o
A Permit for the Retail Sales or Public display of fireworks is required. A completed
application with required documentation and fees shall be submitted for Fire Marshal
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information
Name: Tyson Devries 3 ',mo }
Mailing Address: 23001 NE StateR *3 IN
City: Belfair State: Zip: 9R52P
Contact Number ( 360)2V-7-3-118 a% g
I
Sponsor Information
Name: Belfair Assembly of God Youth
Mailing Address: 23001 NE state Rt 3
City: Belfair State: TqA Zip: 98528
Contact Number ( 360 )277-3778
Washington State Fireworks License Information (Copy Required)
License No.: Date of
WSPFIr-00022 Issue: Feb, 2 2004
❑ Pyrotechnic Operator License ❑x Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: (see attached)
Insured:
Certified Holder:
Location of stand/display
Address: Safeway, 23961 NE S-tate Rt R, aei fa;,-
Directions to Site:
Parcel Number: - -
Legal Description:
Legal Property Owner: Safeway Inc
* * Please see the reverse side to complete your application
....._..:... _
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT WWH6551
TO: Governing body of city, town, or county in which DATE OF 2/18/2004
fireworks stand will be located. I APPLICATION:
Applicant Name (Licensee): Address, City, State:
TYSON DEVRIES PO BOX 1436, TACOMA, WA 98401
Contact Person (If other than applicant): Address, City, State:
BELFAIR ASSEMBLY OF GOD PO BOX 1436, TACOMA, WA 98401
WWH6551
Location of proposed fireworks stand: [Enclose drawing of stand locationAPPRONVED
SAFEWAY#1571, 23961 NE STATE RT 3
tAASQN Ct;L'NZY
Manner and place of storage prior, during, and after sales dates: E - -ALS Of =C
ON SITE WITH SECURITY - - 6
State Licensed Fireworks Supplier: 0rareti 01_ra a-C teq,4^'d t3 h*. on f b s'
American Promotional Events NW, PO BOX 1436, Tacoma, WA 9401,
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FI1EZEWO-D.KS STAND PERMIT
For The Fireworks Sales Year Of: 2004
(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
MASON COUNTY local governing authority, the named person, firm or
organization is hereby authorized to sell U.N. 0336 I AG Consumer fireworks at the location designated
herein between the following date and times:
Sales For July 41h Sales For December 31"
From: From:
Sponsor: BELFAIR ASSEMBLY OF GOD
Location FEWAY#1571 23961 NE STATE RT 3
/s/ /s/ �'t-Fbr TYSON DEVRIES
S gnature of Official Granting Permit '✓ Signature of Applicant
Title: Agency: OOLN
Date:C Permit Number: Wiz- �6�b(41
Licensee Name: TYSON DEVRIES License Number: 00022