HomeMy WebLinkAboutFIR2004-00015 Fireworks - FIR Application - 3/9/2004 oY +t GFP Izo
OD:23/2004 14:20 FAX 360 427 7798 MASO�CO PERMIT CTR 41"� 16002/006
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Mason County
MULUM Fireworks Permit Application31 l
_ PO BOX 186 //
426 W Cedar St Permit# FIRQO 0�f --ODD
1 S
Shelton WA 98584
(36Q)f27-9670 ext 273 Receipt #
CK #
MAR U 9 2004
Date Received 3- Q— 0
426 W; CEDAR ST:
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
revi�w. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information �,� Q�t,t.� H
Name: —' ,
Mailing Address: 5(,-Y-t /V y k1V NIA U�ypc _
City: St)COM A State: Gy rI Zip: gyp
Contact Number ("L`�� 3tg 7•�7�
Sponsor J_uf9 r=ftn 1
Name: _ Lc ^J�PC41
Mailing Address: ^^ r - tt- VJ W 2U ;
Clh' (� % �� State. ��/< Zlp.
Contact Number 12 S J� _ �
Washington State Fireworks License Information (Copy Required)
License No.: Date of
r
S l\J -voon 1 Issue: f
[] Pyrotechnic Operator License Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider:
�
Insured: 'r" r �.S, .i i � r3 .
G�rtitied Holder: , 0jk,,F
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Location of stand/display
Address: 4. rej' n " Hwu 3 `31 /V i, :^ lj-? ; lei✓
Directions to Site:
Parcel Number: t a <)C):
Legal Description: TV-
Legal Property Owner:
* * Please see the reverse side to complete your application
O1`C23/2004 14:20 FAX 360 427 7798 MASON CO PERMIT CTR Q 003/006
The following pertinent information MUST be provided on the site diagram below
Locations and Setback distances from the back, sides and fitont of retail sales stands or )
designated Ja areas to.
Fire Hydrants • Pmperty Lines
• Buildings Parking
i • Combustibles • Public Roads and Right of Ways
• Fire Lames Private Roads and Right of Ways
• Trees/Brush • Landmarks
• Utilities and Gas Mortar separation distance
• Desi ated landin area
i
SEC
A0plicants Affidavit
certify that the information provided herein is accurate and that compliance with
all County, Stat ral laws pertaining to the sales or discharge of fireworks
shall be m ' 'ned.
SrDate
FOR OMCfAL USE ONLY BELOW THIS LINE
ALepted By: Date:
w APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
TO: Governing body of city,town, or county in which DATE OF
fireworks stand will be located. APPLICATION:
Applicant Name: Address,City, State:
lDYvt 5ar Y\.XA 60ct
Sponsor (If other than applicant): Address, City, State:
'TaN a PENS-ITrS 50 ka 'ma &vie q
Location of proposed fireworks stand: [Enclose drawing of stand location]
%-, Car u/y- V6 34;4' wil- Ltn &f Lot,.(
Manner and place of storaLre prior, during,and after sales dates: APRO`, ED
All fjo wmVs o-vA sk sko—dld,'�-iptem e4 `ON COUNTY
State Licensed Fireworks Supplier! ;-S OF !C
,4=., -
kA \ of n 1 tk �- 1 I r , ,/ �i93C�;CS SU��E6� 1Q e�]yi Q'
�` re reCda.1 is be sn lnb jIf
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWORKS STAND PERMIT
For The Fireworks Sales Year Of: -200
(Must be conspicuously displayed at all times while the stand is open to the public)
By virtue of having been granted a license by the State of Washington and this permit from
U,smn cxs&k4m as the local governing authority, the named person, firm or
organization is hereby uthorized to sell U.N. 0336 I AG Consumer fireworks at the location designated
herein between the following date and times:
Sales For July 41h Sales For December 31s'
From. j'uyiy-. 2 , V)OV- l From:
To: To:
Sponsor: �Gt�jvl 30l bPVS-�,r'S
Location: 5& t,or r ��v �' � �h �l� a l r
/s/ �U—Ik /s/
Si�nature of fficial Granting Permit Signature of Applicant
Title: Agency:x(YV,S�,
Date: Permit Number:_T3P�Z ate`{ —CO�J S
Licensee Name:Tah,jVG S. License Number: Cc c