HomeMy WebLinkAboutFIR2008-00040 Fireworks - FIR Application - 5/28/2008 4 %
N w Mason County
Fireworks Permit Application 1
PO BOX 186 Permit# FIR Zw — 600[ V
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 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
i Name: RANDY NEATHERLIN
Mailing Address: PO BOX 445
City: BELFAIR State: WA Zip: 98528
Contact Number (360 ) 731-3849
Sponsor Inforruation
Name: NORTH MASON PEE WEE
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 FX_1 Fireworks Stand License
Bond or Certificate of Insurance -
(Copy of Certificate/ Bond Required)
Provider: SEE ATTACHED
Insured:
Certified Holder:
Location of stand/display
Address: QFC NE BELFAI WA rC �.•••,j „ w
Directions to Site: 003 Ns- T-
LiJ�Par el Number: /�3Z9 - !/Z r 'ry
Description:
gal 01operty Owner.ItC
10m IL
* Y'lease see the reverse side to complete N our a1�1 lic n/act
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The following ertinent information MUST be rovided on the site diagram below
Locations and Setback distances fiom the back, sides and front of retail sales stands or
desigclated 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
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 OFFICIAI. USE ONLY BELOW THIS LINE
Accepted By: Date:
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
WWM6505
TO: Governing body of city,town, or county in which DATE OF MARCH 21,
fireworks stand will be located. APPLICATION: 2008
Applicant Name: Address, City, State:
NORTH MASON PEE WEES 2120 MILWAUKEE WAY, TACOMA„ WA 98421
Sponsor (If other than applicant): Address, City, State:
RANDY NEATHERLIN 2120 MILWAUKEE WAY, TACOMA„ WA 98421
Location of proposed fireworks stand: [Enclose drawing of stand location]
NE 1403 OLD BELFAIR HWY QFC
BELFAIR, WA
Manner and place of storage prior, during, and after sales dates:
ON SITE WITH SECURITY
State Licensed Fireworks Supplier:
American Promotional Events NW 2120 Milwaukee Way, Tacoma, WA 98421
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWORKS STAND PERMIT
For The Fireworks Sales Year Of 2008
(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
MASON COUNTY the local governing authority, the named person, firm or organization is hereby
authorized 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 31"
From: Q -2 gj -Dg 0 / From:
To: yg Q� / To:
Sponsor: _NORTH MASON PEE WEES
Lo ti n: FC NE 1403 OLD BELFAIR HWY BELFAIR WA
/s s/ _ FOR RANDY NEATHERLIN
Signature o ficial Granting P iit Signature of Applicant
�
Title: F 1A �S� Agency:
Date: 04o_a.9--O S Permit Number: F)A 2 a08 _ 0 00y
Licensee Name: NORTH MASON PEE WEES License Number:SOU
3000-420-013 (Rev.105)