HomeMy WebLinkAboutFIR2008-0039 - FIR Application - 5/28/2008 ► Mason County
M M I Fireworks Permit Application
PO BOX 186 Permit# FIR
426 W Cedar St
Shelton WA 98584 Receipt #
(360) 427-9670 ext 273
CK #
Date Received �h'-6
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.
I Applicant Information
Name: RANDY NEATHERLIN
Mailing Address: PO BOX 445
City: BELFAIR State: WA — zip: 98528
Contact Number Q360 731-3849
Sponsor Information —
Name: NORTH MASON PEE WEES
Mailing Address: PO BOX 445
City: BELFAIR State: WA Zip: 98528
Contact Number (360 ) 731-3849
Washington State Fireworks License Information (Copy Required)
License No.: Date of
WSPFL-00506 Issue: 04/01/08
❑ Pyrotechnic Operator License 91 Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate J Bond Required)
Provider: SEE ATTACHED _
Insured:
Certified Holder:
Location of stand/display aj Jj.J
Address: RIED REALTY —2�-}- NE HWY 3 BELFAIR, WA
Directions to Site: �YI /q
I W 1 V _ py1
Parcel Number: ah u
Legal Description:
' z
Legal Property Owner:
I2.32 3� -- oo�r� -
,
Please see the reverse side to complete `your appli l'aden,5� �. if
G F
rvcii tt
The following pertinent information MUST be rovided 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 a Property Lines
Buildings a Parking
+ Combustibles 0 Public Roads and Right of Ways
® Fire Lanes ® Private Roads and Right of Ways
Trees/Brush @ Landmarks
0 Utilities and Gas Mortar separation distance
® Designated landing area
SEE ATTACHED DIAGRAM
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 FOR RANDY NEATHERLIN Date
FOR OFFIC'IAI. USE ONLY BELOW THIS LINE
Accepted By: Date:
l