HomeMy WebLinkAboutFIR2008-00024 Fireworks - FIR Permit / Conditions - 4/8/2008 4
Mason County
Fireworks Permit Application
f PO BOX 186
426 W Cedar St Permit# FIRQD�'U
Shelton WA 98584 Receipty� ''
��) 427-967Q ext 273
. CK #
Date Received 7 8 O-r
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A Permit for thSales or Public display of fireworks is required. A completed
application witAMequTed 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
Mailing Address: 23001 NE STATE RT 3
City: BELFAIR State: WA Zip: 98528
Contact Number (360) 277-3778
Sponsor Information
Name: BELFAIR ASSEMBLY OF GOD
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.: Date of
WSPFL-00848 Issue: 02/12/2008
❑ Pyrotechnic Operator License n Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: SEE ATTACHED INSURANCE
Insured:
Certified Holder:
67093
Location of stand/display
Address: SAFEWAY #1571 23961 NE ST RT 3 BELFAIR, WA
Directions to Site:
Parcel Number: -
Legal Description:
Legal Property Owner: SAFEWAY
* * Please see the reverse side to completer
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