HomeMy WebLinkAboutFIR03-00043 Fireworks - FIR Permit / Conditions - 10/13/2003 Mason County
Fireworks Permit Application
HE UUM
PO BOX 186 Permit# FIR
426 W Cedar St -
' Shelton WA 98584
(360) 427-9670 ext 273 Receipt # -
CK #
Date Received / f
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 MarshAjCT 13 2093
review. A permit will be issued upon satisfactory site inspection by the Fire Marsh45 W. CEDAR STi
Applicant Information
Name: c HA 15 W I LL i,4M �ST�e I/' s ��Tigit /mac
Mailing Address: 571 A-E- Agpg4&D LN
City: State: w/9 Zip: a)b 31(
Contact Number (34o)69z zFg(N) ��_476- 8Ti3tw)
Sponsor Information
Name:
Mailing Address: 7-4va F= �far�,Pc�s fnR
City: ffFc.Ft4/2 State: t,Ci/4 Zip: ��SZt3
Contact Number (� )2z7- z«off C1}i�rl/ c�sBY-f3551'�,e./n�iPpc)
Washington State Fireworks License Information (Copy Required)
License No.: Date of �xl',• /l3/�oq
Issue:
t9 Pyrotechnic Operator License ❑ Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: G -5, . lAle_ (LL nes of L o.�G�iv
Insured: 5TRiPk-5 /efzT�I/L, i/I/c
Certified Holder: AIoW-TH Ae,gg W y�Gy sce,00L
Location of 466neWdisplay 00k 4FIF t-V F,45r orc LCZIZ-09�/ low S'
Address: Zcb e, �i9/L�P�rS 9,e, 'Url 091R t cw07
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Directions to Site: -,gK¢ tf3 N�Tis� f, �s, Tom,.—Tu.C•tf �G�T ary
le-84K curo.-,ieP Tc/RN MW44z FT// IZP NM MS !o-,7,0f.0/,V.4 RVZAWA,6c,or;
Parcel Number:
Legal Description:
Legal Property Owner:
* * Please see the reverse side to complete your application
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The following 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 0 Private Roads and Right of Ways
• Trees/Brush • Landmarks
• Utilities and Gas • Mortar separation distance
• Designated landing area
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 Date %3�03
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: