HomeMy WebLinkAboutFIR2007-00019 fireworks - FIR Application - 6/15/2007 '� Mason County
Fireworks Permit Application
�B � PO BOX 186
426 W Cedar St Permit # FIk-�0011
9
Shelton WA 98584 Receipt # 7e
(360) 427-9670 ext 273
CK # �y�
Date Received L115�
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 Information
Name: RANDY NEATHERLIN
Mailing Address: NE 291 ROY BOAD RD
City: BELFAIR State: WA Zip: 98528
Contact Number ( 360 ) 275-3194
Sponsor Information
Name: NORTH MASON PEE WEES
Mailing Address: NE 291 ROY BOAD RD
City: RELEATR State: WA Zip: 98528
Contact Number ( 360-) 275-3194
Washington State Fireworks License Information (Copy Required)
License No.: Date of
WSPFL-00506 Issue: 03/19/2007
❑ Pyrotechnic Operator License ® Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: SEE ATTACHED INSURANCE
Insured:
Certified Holder:
Location of stand/display
Address: QFC NE 1403 OLD BELFAIR HWY BELFAIR, WA
Directions to Site:
Parcel Number: 3 - -
Legal Description:
Legal Property Owner: QFC
* * Please see the reverse side to complete your application
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
• 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 / o
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: