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9 <br />THiS FORM IS INTENDED TO BE USED AS A GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING <br />JURISDICTION AND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON <br />WASHiNGTON STATE <br />PUBLIC FIREWORKS DISPLAY PERMIT <br />Name of Event Everett July Fourth <br />Street Address Barge located 850 feet east of Jetty Island <br />City Everett <br />County Snohomish <br />Event Date 7/4/14 Event Time Approx. 10:00 <br />❑AM QPM <br />Applicant's/Sponsor's Name Everett July Fourth Foundation Phone No. 425-257-7101 <br />Pyrotechnic Operator Wayne Ulrich License No. P-02850 <br />Experienced Assistant's Name Scott Anderson <br />General Disptay Company Name Western Display Fireworks Ltd Phone No. 503-656-1999 <br />Attach a separate piece of paper and/or copies of the following documents: <br />• The number of set pieces, shells (specify single or multiple break), and other items. <br />• The manner and place of storage of such fireworks prior to the display. <br />• A diagram of the grounds on which the display is to be held showing the point at which the fireworks are to be <br />discharged; the location of all buildings, highways, and other lines of communication; the lines behind which the <br />audience will be restrained; and the location of all nearby trees, telegraph or telephone lines, or other overhead <br />obstruction. <br />• Documentary proof of procurement of Surety bond or public liability insurance. <br />Local Fire Code Authority <br />Authority Having Jurisdiction Everett Fire Department <br />Name of Permitting Official Eric Hicks <br />Title Assistant Fire Marshal <br />Permit Granted: '(es <br />Restrictions/Notations Inspection required <br />Phone No. 425-257-8123 <br />2Yes, with Restrictions (see "Notations" below) ❑ No <br />Signature or Permitting Official <br />5/16/2014 2014-054 <br />Date of Approval Permit Number <br />If approved, this permit is granted for the date and Time noted herein under the authority of the International Fire Code in <br />accordance with Revised Code of Washington 70.77 and all applicable rules and ordinances pertaining to fireworks in this <br />jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is <br />responsible for any and all activities associated with the firing of this show. <br />MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION <br />300J-120-050 (R 31 3) <br />35 <br />