HomeMy WebLinkAboutFIR2006-00028 Fireworks - FIR Application - 6/22/2006 � '' `1' � ' ' Masdn County
Fireworks Permit Application
PO BOX 186 Permit# FIR 1,00t
426 W Cedar St '
Shelton WA 98584
(360) 427-9670 ext 273 Receipt # t 1 I
CK #
Date Received _ZZ�
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 nformation
Name: RoAkA Q Q
Mailing Address: CC,t v oa�l
City: ( State: iA Zip: q SZ $
Contact Number
Sponsor Wormation
Name:
Mailing Address E W c
City: State: Zip: a t5 Z R
Contact Number
Washington State Fireworks License Information (Copy Required)
License No.: W S Q F L —p() _,So& Date of
Issue: 3-aG
❑ Pyrotechnic Operator License �ireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Requir d)
Provider: hcc, S� ,Ip�1 s a, 1l,Gyh s nC
Insured: _ ,,I
Certified Holder: MaSUYAQVCrn p S
Location of stand/display
Address: f-A ►�Ib3 �� �( � C1w�
Directions to Site.
Parcel Number: ( 15 _ O
Legal Description:
Legal Property Owner: (►
* * Please see the reverse side to complete your application
,e
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 Private Roads and Right of Ways
• Trees/Brush • Landmarks
• Utilities and Gas • Mortar separation distance
• Desi ated landing area
9f
v
t
Applicants Affidavit
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
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: