HomeMy WebLinkAboutEVE2008-00002 - PLN General - 7/23/2008 PREAPP: DULY 31, 200f1
(� TIME: 9:00/9:15-10:15
Mason County
Carnival, Circus or Like Enterprises Application
MCC Section 5.12.010
Return To: Mason County Dept of Community Development Phone: (360) 427-9670 ext. 352
PO Box 186 Fax: (360) 427-7798
Shelton, WA 98584
This application must be completed, signed and forwarded to the Mason County Dept of Community Development Office
at least sixty (60) days prior to the first day of the event. Any misrepresentation in this application or deviation from the
final agreed upon route and/or method of operation described herein, may result in the immediate revocation of the
permit. Please type or print information clearly and attach additional sheets as necessary. Once application has been
submitted, the applicant will be required to schedule a pre-application meeting with county staff to discuss event details.
EVENT
Event Name: �.so&v 0004y EK+nr_Im Si�04,5 aS2 i' k
Event Date(s): Day(s) of the Week: SAT Time(s): 10.44 �6 /D A,"
Event Address: A„e ry Sti e 11an dJA-. f8 s -ay
Legal Description (TPN):
Size of Property (if applicable): 5-4 Arres
Event Crowd Size: Participants: /bU^' Spectators: /-Z K ^-�l Volunteers/Staff: e!O-s"O
Has event been held previously? No X Yes ❑
If yes, what were the dates of the event &where?
Any change from previous events?N, o ❑ Yes ❑
If yes, please attach list of changes or this year's request.
APPLICANT INFORMATION
Applicant's Name: Ljjer G. 6-u66eet
Applicant's Address: 70 E, Greve..,e�ooaNre /.v• _Z�e lam+ 414a.
Phone Home: 390-y2;7-3778 Work:
Numbers:
Pager: Cellular: ,3�
Fax: Email:
Owner's Name: Greoa �GiS�t V
Owner's Address: I7S`/7 /.5-rz .�t.�c /V S.(ar��:�-� �✓a 9CW,5—.5 -
Phone Numbers: Home: Cellular:
Page 1
EVENT DETAILS
Check appropriate category below and fill in details or numbers, size and type. Leave blank if not applicable.
Alcohol: ❑ Wil alcohol be served or available? Will alcohol be sold? No Yes ❑
N NoX Yes ❑
Booths/Vendors: How many booths? ^, How many vendors?� v
Entertainment: Sound System: Describe:
Accoustic ❑ Amplified AN u•ray a.o14 /rn / { e ds, �Da���9
04�
Food Will food) be served or available? Will fdod be sold. No❑ Yes)KI
No ❑ YesR If Yes, by whom?
r Pa,'
Water: Potable? Non- able?
y
Electricity Source: Q' Generators: How many? Size:
yl s 04,2dP.U. P S r
Sanitary Facilities How many? Handicapped Accessible:
is- yelo
Rides: ❑ How many? Type:
lydwe
Land Clearing or ❑ Yes ❑ No Describe:
Grading:
INSURANCE INFORMATION
Evidence of insurance must be provided no less than 15 days prior to event. "Mason County" at 411 North Fifth Street,
Shelton,WA 98584 must be named "additional insured." Minimum Limits as applicable: $1,000,000 Commercial General
Liability, $2,000,000 Liquor Liability, $500,000 Auto Liability. All limits and coverage may be adjusted to meet exposure
as determined by County Risk Manager. "Carnival, Circus or Like Enterprises"license/permit will not be issued until
insurance has been approved.
Mason County Risk Manager:
lone Siegler
411 North Fifth Street Phone: (360) 427-9670 ext. 423
Shelton, WA 98584 Fax: (360) 427-8437
Falsification and/or misrepresentation in completing this application may result in rate adjustment or event cancellation. I
UNDERSTAND THAT CHANGES TO THE ABOVE DETAILED PROGRAM REQUIRE IMMEDIATE NOTIFICATION TO
MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT.
I, the undersigned representative, have read the "Carnival, Circus or like Enterprises Application" and the
Policies and Procedures contained herein, and I am duly authorized by the event organization/business to submit
this application on its behalf. The information is complete and accurate.
PRINT APPLICANT'S NAME: �,GSTG✓� C• TCJ/'�/+�t�"�
SIGNATURE OF APPLICANT:
SIGNATURE OF PROPERTY OWNER ( IF DIFFERENT THAN APPLICANT):
DATE OF APPLICATION: FEE AMOUNT COLLECTED:
APPROVED BY: DATE OF APPROVAL:
Page 2
' v P rctN can 1
tot ol
----------
or I�I
4 1
1 !
O rTl 1
77 1
� 1=
I
� sI
4 I
FtJ.ck,
v Vu 1
rt�
u �Q
1 ��
L
IL►� CO+�FCSi(v1,
CL
i
FI}fuc e
cry
P I
l �
t � o
1
u
l
�x /4 m-fee-f S P 45Fe- '&Vt �l
�" � r �
1 '
MASON COUNTY FIRE MARSHAL
*'g
Mason County Bldg.III 426 W Cedar St
PO BOX 186 Shelton,WA 98584 -
(360)427-9670 Ext.273
Al coc),�/� EKi SR,� Fli/d1•FG
CODE ENFORCEMENT FIRE INSPECTIONS FIRE INVESTIGATION PUBLIC EDUCATION
Lg57W�0- 70-0114"Pof�- M6tiQ. �clfil3�T7o.+/
AAL&XA'r- tfYlf-V S�irfB`"B S,�z�,6S
5 �,2 �k/hB,rior✓ ..- �1oTdiQ cYGI.�,S ��.
0114
CAk rro
e g M14�IS PRE-APP CHECK LIST ,4�r s,��,�
Y ✓!j
,akAA ;4-0A1 'S0'v
l Construction Type
• Occupancy Type/Load_
Water Supply & Fire Hydrants q.)b FAP r LS�4sE s
• Fire Flow 07'
Emergency Vehicle Access c4±!!
/1!d Pax/ / cGes ,
V Addressing k 2-8 — c J•� r�w'Tc �os
�• Exits �it1S�,eft' �cl`lliJG� F��, ? p,E►,glt y �S'r cJGT c�2�'�i
• AFA
• Sprinkler System
Ca&Ze SO) N Aowoblev F/x0 Fi.4i
• Fixed Fire Suppression System A:-Ab0
• Fire Extinguishers fy�� At -VL- 3144D,&- �,,/ �n of r O&V-Pt - AO'W,41mom
• Knox Box
• Storage/Type/Height
PA44b✓�;- 7>j')gS 7-o a- -Si5w 0 57t vM Fed Fk
Gas Meters/Tanks D AS A (/ '7� 5 ,�,� i,.,t* 577W DA
Other
A42- AZVEVEn1i i/vs/ cTTt�tJ Gd.Q F � cooK�i r! EkTli✓�,�,S�s'�5� �i.�e?'�GSSS/
AP,f AA,v -T,14,-Ok�3 s�scvQ�
-t6,41L�sd (
3v X /Yo Gr2a'b-