HomeMy WebLinkAboutFIR2003-00053 - FIR Application - 2/4/2003 Mason County
Fireworks Permit Application
_ � � � PO BOX 186
426 W Cedar St _ Permit# FIR,)00,,j -('t7s,3
Shelton WA 98584 Receipt #
(366) 427-9670 ext 273 _
CK #
Date Received RECEIVED
i08 12 2003
A Permit for the Retail Sales or Public display of fireworks is required. Aekoorrtkc �R ST,
application with required documentation and fees shall be submitted for ire ars all
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information
Name: Coop r
Mailing Address: V, -s S e
City: POr-�- OroU�trab St e: Zip: 6((65�V�2
Contact Number ��
Sponsor Information
Name: DAUt, C Oo r
Mailing Address: W G
City: r o State: I Zip: d {�
Contact Number C,�,r
Washington State Fireworks License Information (Copy Required)
License No.: Date of
Q l 0,4-, 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
i r
Address:
Directions to Site:
Parcel Number: -bg - LA\ - (cC7F3 I
Legal Description:
Legal Property Owner:
* * Please see the reverse side to complete your application
I
I '
The following pertinent information MUST be rovided 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 r
•` 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, St Federal la ert 'Wing to the sales or discharge of fireworks
shall be mai ta- ed. �
Signed Date —
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date: DEC 2 6 2003
426 Wm CEDAR STg