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10 <br />PART I <br />urJr. <br />APPLICATION <br />FOR PUBLIC FIREWORKS DISPLAY PERMIT <br />ch display is to be conducted <br />DATE OF APPLICATION <br />5/6114 <br />y r _ _ ._ .-_ __ - . _.. , - <br />_APP_L1CANT <br />NAME <br />Wolverine West Fireworks <br />ADDRESS <br />PO Box 99095 - Seattle, WA 98139 <br />PHONE <br />206.459.0917 <br />SPONSOR <br />Everett Aqua Sox <br />ADDRESS <br />3802 Broadway, Everett, WA 98201 <br />PHONE <br />425.258.3673 <br />1'XROTECHNIC OPERATOR' '77 . - : ... __..._: <br />NAME <br />John Fisher <br />ADDRESS <br />1819 Hoyt Ave, Everett, WA 98201 <br />LICENSE # <br />P-02764 <br />`:-NAME..OF ASSISTANTS :(at.leastone required) ..:.. ,.._ <br />NAME <br />Jim Fisher <br />ADDRESS <br />17418 W. Lake Goodwin Rd Stanwood 98292 <br />AGE <br />34 <br />NAME <br />ADDRESS <br />AGE <br />-.EXACTLOCATION O P_ROPOSED>D1SP-LAY, = <br />LOCATION <br />Everett Memorial Stadium 3900 Broadway, Everett, WA 98201 <br />DATE <br />2014: 6/13, 6/27,7/4, 7/18, 7/25, 8/16, 8/23 <br />TIME <br />10pm+/- following the baseball games <br />N►IMBER AND KINDSOFFIREWORKS TO-BE.OISPLA FED =- . , i ...:: - -_ <br />(42) Cakes, (50) 1.75" Shells, (6) 50mm Close Proximity Comets to be fired upon <br />Aqua Sox scoring a run. These comets are 1.4G electrically fired & are designed <br />to be used within 25' of spectators. <br />;_HANDIER A_PLACE OESTORAGE PRIOR30 DISPLAYISublecf tapprovat_of Local Fire`AuttiOri: <br />In our approved magazines V..--- <br />SIG�E OF APPLICANT <br />. EiNdktiC.IAL RESPONSIBild _ ,;:_ __ . ' _ t: _ .. . - <br />BONDING OR INSURANCE COMPANY <br />Professional Program Insurance Brokerage <br />(Mark One) <br />or certificate of insurance attached <br />or certificate of insurance on file with State Fire Marshal <br />of insurance shall provide minimum coverage of <br />bodily injury liability for each person and event, <br />and $25,000 property damage <br />X Bond <br />❑ Bond <br />Bond or certificate <br />$50,000/$1,000,000 <br />respectively, <br />ADDRESS <br />371 Bel Marin Keys Blvd. Ste. 220 <br />Novato, CA 94949 <br />PART II <br />PERMIT <br />PERMIT # DATE: <br />In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a <br />fireworks display as per the above application. <br />NAME: <br />RESTRICTIONS: <br />(Full name of person, firm, or corporation granted permit) <br />Permit not valid without verification of <br />the appropriate State Fireworks License <br />LICENSE NUMBER: <br />(Signature of Official granting permit) <br />(Instructions on reverse side) <br />(Title) <br />3000-420-050 (R 02/05) <br />Distributj: WHITE (A): Local FireAuthority; YELLOW (B): Permitee <br />