HomeMy WebLinkAboutFIR2004-00037 - FIR Permit / Conditions - 6/18/2004 K Mason County
Fireworks Permit Application
PO BOX 186
Permit# FIR cam/_pm°�
426 W Cedar St 7
Shelton WA 98584
(360)427-9670 ext 273 Receipt #
CK #
J Date Received
A Permit for
o 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
Mailing Address: / .-v e a g/ g."
City: .el-/%F,, State: w:� Zip 9 t1Sa
Contact Number (3�o) a S _ q5_
Sponsor Information
Name:
Mailing Address: 0 A-0 V 41U S
City: a,/,", r State: Zip: ?,f
Contact Number (3 Gv ) Z )Jr _ %3
Washington State Fireworks License Information (copy Required)
License No.: Date of
ssue: .a,����' /4 r" oy
[] Pyrotechnic Operator License IVI Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Requited)
Provider:
Insured:
Certified Holder:
Location of stand/display
Address: 2 /� .3 - C/.
Directions to Site:
Parcel Number.: la -4 / 00 g,
Legal Description:
Legal Property Owner: l
i
* * Please see the reverse side to complete your application
1
The foRowing pertinent information MUST be provided on the site diagram below
Locations and Setback distances from the back, sides and front 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
,l
Applicants Affidavit
I certify that the information provided herein is accurate and that compliance with
all County, State and Federal laws pert 'ning to the sales or discharge of fireworks
shall be maintaine .
Signed Date /- D
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: