HomeMy WebLinkAboutFIR2003-00013 Fireworks - FIR Application - 4/22/2003 Mason County
Fireworks Permit Application
PO BOX 1.86
Permit#FIR
426 W Cedar St 42Z—Q-0-0-13
Shelton WA 98 34 Receipt # ; 0�[14 ,�,
(366)427-9670 ext 273
CK # g q
Date Received Y.
A Permit for the Retail Sales or Public display of fireworks is required A completed
application with required,documentation and fees shah be submitted for Fire Marshal
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information
Name: Tyson Devri es
Mailing Address: 23001 NE State RT 3
City: Belfair State: WA Zip: 98528
Contact Number ( 360)277-3778
Sponsor Information
Name: Bel fai r Assembly of God Youth
Mailing Address: 23001 NE State RT 3.
City: Belfair State: WA Zip: 98528
Contact Number ( 360 ) 277-3778
Washington State Fireworks License information (copy Required)
License No.: bate of
01879 Issue: 2-4-03
❑ Pyrotechnic Operator License ® Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certtflcate/Bond Required)
Provider: - Drayton Insurance Brokers, Inc.
Insured: ._ American Promotional. Events, Inc d/b/a TNT Fireworks
Certified.Holder:
Location"of stand/display
Address: Safeway., 23961 NE State RT 3, Belfair
Directions to Site:
Parcel Number: l _ (M b
Legal Description:
Legal Property Owner:
* * Please see the reverse side to complete your application
The fol1owing perdnent,hdormadon MUST bg Rroyided on the site a aw
Locations and Setback distances from the back, sides and Aront of retail sales`stands or
designated display areas to:
Fire Hydrants • Property Lines
• Buildings • Parking
• Combustibles • Public Roads and Right of Ways
• Fire Lanes • Private Roads and Right of Ways
• Trees/Brush • Landmarks
• Utilities and Gas • Mortar separation distance
• Designated landing area
Applicants Affidavit
1 certify that the information provided herein is accurate and that compliance with
all County, State and'Federal laws pertaining to the sales or discharge of fireworks
shall be in ined.
Signed For Tyson Devri es Date 3-7-03
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: