HomeMy WebLinkAboutFIR2008-00042 - FIR Application - 6/6/2008 .Mason County
Fireworks Permit Application
PO BOX 186
Permit# FIR
�,,�,� 426 W Cedar St
Shelton WA 98584
RECUT- (360) 427-9670 ext 273 Receipt #
�11� 4.6 Ito CK # �►
47.6 W. CEDAR ST- Date Received
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: G h" a� day
Mailing Address: 3 2 L
City: ,V State: L,JG` Zip: C� fr U Y- --
Contact Number
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Sponsor Information
Name:
Mailing AddresEf. a ( F R
City: c State: ;L )c` Zip: S`E
Contact Number ( )
Washington State Fireworks License Information (Copy Required)
License No.: Date of
P— Issue:
91 Pyrotechnic Operator License ❑ Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required) nn
Provider: (�. ��cd Spe=G,` l.`c I
Insured: � �Qc' rfcu;C) 4 7
Certified Holder: �C vie /�'tc Zfr
Location of stand/display
Address: D (� U,1eeaJ W4 4
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Directions to Site: ee
Parcel Numb D 72 On D d OLi w i
Legal Descripti . LL)i ='
Legal Property Owner:
�r > LU
Please see the reverse side to complete your applic t ►u ; o :
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The following eminent 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
• Desi ated Iandimg area
0 Pt to
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Applicants Affidavit
I 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 maintained.
Signed
v ^=7 Date
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: