HomeMy WebLinkAboutFW94-0007 - FIR Permit / Conditions - 6/20/1994 PART I GATE OF APPLICATION
APPLICATION 4-11-94
FOR FIREWORKS DISPLAY PERMIT
TO: Governing body of city, town or county in which display is to be conducted. FILE COPY
APPLICANT
NAME ADDRESS TEL.
PYRO SPECTACULARS NORTHWEST P.O. BOX 7160 OLYMPIA WA 98507-7160 �(206) 352-8911
SPONSOR(if other than applicant) ADDRESS
CELEBRATE HOODSPORT P.O. BOX 725 HOODSPORT WA 98548
PYROTECHNIC OPERATOR
NAME ADDRESS LICENSE#
MARK MCDOUGALL P.O. BOX 725, HOODSPORT, WA 3046
NAMES OF ASSISTANTS:(at least one required)
NAME ADDRESS AGE
Jim Goodpaster P.O. Box 84 Hoods port, WA Legal
NAME ADDRESS AGE
David Laney P.O. Box 124, Lilliwap, WA Legal
EXACT LOCATION OF PROPOSED DISPLAY
Hood Canal, Off shore from city
DATE TIME.
July 4, 1994 approx 10:00 p.m.
NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED
2/Strobe Pots 2 2" Gerbs 1/Set Piece 3/3" Mine Bags 23/3" Aerial Shells
190/4" Aerial Shells 15/5" Aerial Shells 66/6" Aerial Shells
1 7" Aerial Shells
MANNER&PLACE OF STORAGE PRIOR TO DISPLAY
ready boxes
(Subject to Approval of Local Fire Authorities) Signature of App ca t
FINANCIAL RESPONSIBILITY (Mark One)
Bonding or Insurance Co.
x Bond or certificate of insurance attached
DRAYTON INSURANCE BROKERS, INC.
Bond or certificate of insurance on file with state fire marshal
Address
Bond or certificate of insurance shall provide minimum coverage of
2500 Center Point Rd., Suite 301 $50,000/$1,000,000 bodily injury liability for each person and event,
BirmincIhm, Alabama 35215 respectively,and$25,000 property damage liability.
PART (PERMIT# FwCl-pool PERMIT ,n
Date 19
In accordance with the provisions of FICW 70.77 and applicable local ordinances this permit is granted to conduct a fireworks display as per
the above application.
Name 15TPz�Afu6q=_
(Full name of person,firm or corporation granted perrMt)
Restrictions:
(Slgna a of oleic I granting permit)
Permit not valid for conduct of display u er y�
without verification of license and ��c�
counter-signature of licensing agency. hle)
WA
COPY"A"—Local Authorit City,Town eraunt
►I CI A `VL � NORTHWEST
FILE Cop
Re: Fireworks display permits within the State Of Washington.
To Fire, Police, Sheriffs Departments and other "Authorities having jurisdiction":
Enclosed is an application for permit, for a fireworks display. The green copy
needs to get back to the State Fire Marshall's office for his records. However,
for whatever reason, some don't make it.
Please send the green copy of the signed permit back to this office, along with
our white permit copy and we will forward all green copies to the state on a
regular basis. If any green copies turn up missing, we can at least send in a
copy of our white copy so the state files will be complete.
Thank you.
Sincerely,
J Larry Mattingly
NW Regional Sales Manager
Pyro Spectaculars • Northwest 9 P.O. Box 7160 • Olympia, Washington 98507 • Tel (206) 352-8911 • Fax (206) 352-0205
DRAYTON INSURANCE BROKERS, INC.
2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067
BIRMINGHAM, ALABAMA 35215 BIRMINGHAM,ALABAMA 35220
TELEPHONE: (205) 854-5806 FAX: (205) 854-5899
CERTIFICATE OF INSURANCE FIL
E Copy, 481356
We certify that insurance as outlined below is afforded the Named Insured under policy A94EG23060 issued by Admiral Insurance Company.
NAMED INSURED: Pyro Spectaculars, Inc. North American Fireworks Company (NAFCO)
P. O. Box 2329 San Diego Fireworks
Rialto, California 92377 Astro Pyrotechnics
Pyro Spectaculars Canada, Inc.
Pyro Spectaculars Northwest
PERIOD: January 13, 1994 to January 12, 1995; Both Days Inclusive.
COVERAGE: Fireworks Display Contractors Liability. Covering against the legal liability of the Named Insured for Bodily Injury
and/or Property Damage caused by, or arising from, the preparation for, the firing of, or the clearance following,
fireworks display(s), FIRED BY THE NAMED INSURED OR THE NAMED INSURED'S EMPLOYEES.
LIMITS OF LIABILITY: A) Each Occurrence $1,000,000
B) Products and Completed Operations Aggregate $1,000,000
The above stated limits of liability apply to each occurrence,except that in respect of Products and Completed Operations
Liability the limits apply in the aggregate.The addition of more than one insured does not serve to increase the limits
of liability.
It is certified that,in accordance with,and subject to,the terms of the above policy,the following SPONSORS Al PROPERTY OWNERS AND/OR
LICENSING AUTHORITIES are included as Additional Insured(s),but only in respect of the legal liability of such Additional Insured(s)for Bodily Injury
and Property Damage caused by the operations of the Named Insured in connection with the firing of the fireworks display(s) stated below BY THE
NAMED INSURED OR THE NAMED INSURED'S EMPLOYEES.
NAME & ADDRESS OF INSURED SPONSORS
PROPERTY OWNERS, LICENSORS CELEBRATE HOODSPORT
P.O. BOX 725
HOODSPORT, WA 98548
ADDITIONAL INSURED: CELEBRATE HOODSPORT, and/or CITY OF HOODSPORT, their officers,
agents and employees when acting in their official capacity
as such.
DISPLAY LOCATION DISPLAY DATE(S)
Off Float on Hood Canal July 4, 1994
This insurance applies automatically if the described display is fired on any alternative date because of cancellation on the date shown due to weather
or other cause; however, IN NO EVENT WILL COVERAGE APPLY TO BODILY INJURY OR PROPERTY DAMAGE SUSTAINED AFTER January
12, 1995.
Notwithstanding any requirement, term or condition of any contract or other document with respect to which the certificate may be issued, or may
pertain,the insurance afforded by the policy described herein is subject to all the terms,exclusions,and conditions of such policy. For particulars concer-
ning such terms,exclusions,and conditions each Additional Insured is referred to the policy documents in the possession of the Named Insured. Should
the above described policy be cancelled before the expiration date thereof, the issuing company will mail 30 days prior written notice to the above
named Additional Insured(s).
DRAYTON INSURANCE BROKERS, INC.
April 11 , 1994
DATE 5;TRINGER, PRESIDENT
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FILE COPY
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