HomeMy WebLinkAboutFIR2006-00018 Cancelled Fire Works Stand - FIR Permit / Conditions - 12/26/2006 =+ 05 03,'2000 12:4: FAX 360._427 7798 MASON CO PERMIT CTR 001
Mason County
Fireworks Permit Application
PO BOX 186 Permit# FIR O� IP
426 W Cedar St
Shelton WA 98584 Receipt #
(360) 427-9670 ext 273
CK #
Date Received
A Permit for the Retail Sales or Public; display of fireworks is required. A wrnpleted
application with required documentation and fees shall be�subrnitted for Fire Marshal
review, A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Appliennc Informati,,n
Name: —Tj t4lg , V041 ./5 g
Mailing Address: leo i3 Tc y _
City: L4 c 67 State: Gs�f� �Zip: � y U
Contact Number
I
Sponsor Information
Name:
Mailing Address: pe
City: c fRo'�i/,-L e� State: G��,� — Zip: <7
Contact Number S'd
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Washington State Fireworks License Informatlon (copy Required)
License No.: Date of
Gam' 5 6)6-7 Issue: 4 don G
❑ Pyrotechnic Operator License Fireworks Stand License
Bond or Certificate of Insurance
(COPY of Certificate!Bond Required)
Provider: OR l)Y7�)N /f'S��/ ,�cE.' 41eok[�; ;
Insured:
Certified Holder,:
Location of stand/display
Address: _/G'�
Directions to Site:
Parcel Number: 3.,Z!2 ycjf p
Legal Description: --
Legal Praparty Owner: _,.C - 47Tr � Uk`GtYI _
* please see the reverse side to complete your application h �
p?,O3-'2oetl_12:42 FAX Slip 427 7 799 MASON CO PERMIT cm 2002
The foRowing ptrtiuent 1nf'ormatinii MAST be prodded on the site diagram below
Locations and Setbcick�liWfWIZps f em the back, sides and front of retail sales stands or
desigl�aied display areas to: - —- --
• Fire.Hydrants • Properly Lilies
• Biuldings . Puking
• Combustibles • Public Reads aad Right of Ways
• lore Lanes o Private Roads and fiikht of Ways
* Treeg/Bnist_i • Landmarks j
• Utilities and Cray • Mottar Separation distance �
----- D05 tod landiaz area
uro itvl'o Silo
Nc- 79� /twY3
Ne a 3770 #wY3
Piz2q " � I
%*nary �,p(`j�7 ro /3tZfitlK a C�N�Z
i� G I" e sv�f.sl�t��N �j''Ja 5/J
a
37 7��
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/1-0/z 111M 30
Applicants Affidavit -- ---- — __
I Certify that the infom7ation provided herein is accurate and that compliance with
all County, State and Federal laws pertain; try the sales car discharge of fireworks
shall be rn ined.
Signed Date
FOR O FMCIAL IyS:, ONLY Bt'LOW MS LINE
Accepted By: _.�-------.----------- T_►ate;