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HomeMy WebLinkAboutFIR2004-00036 - FIR Application - 4/16/2004 Mason County Fireworks Permit Application PO BOX 186 426 W Cedar St Permit # FIR ^ (_ �Co Shelton WA 98584 i (360) 427-9670 ext 273 Receipt # 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 Name: Mailing Address: Z City: -/Iw/&a" State: G,IA Zip: Contact Number (goo ) a-7 t Sponsor Information Name: /� Mailing Address: City: 4 ,: State: r*.i.0 Zip: Contact Number } Washington State Fireworks License Information (Copy Required) License No.: Date of f J 7 Issue: ❑ Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: Insured: Certified Holder: Location of stand/display Address: C�3�ti ©/� /�',,, T Hwy ��r7�,/✓ S.ud� Directions to Site: Parcel Number: f�' ?��q - �_ l Legal Description: Legal Property Owner: (2 * * 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 • Desi ated landin area Applicants Affidavit I certify that the information provided herein is accurate and that compliance with all County, State and Federal lavy s pertaining to the sales or discharge of fireworks shall be maintai d. , Signed Date ,,� cv� FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: