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l5 <br /> DART I ` .••.. APPLICATION DATE OF APPLICATION <br /> ur FOR PUBLIC FIREWORKS DISPLAY PERMIT 5/19/15 <br /> TO:Governing body of city,town, or county in which display is to be conducted. <br /> �,` <br /> NAME ADDRESS PHONE <br /> Wolverine West Fireworks PO Box 99095 -Seattle,WA 98139 206.459.0917 <br /> SPONSOR ADDRESS PHONE <br /> Everett Aqua Sox 3802 Broadway, Everett,WA 98201 425.258.3673 <br /> ;PYROTECHNIC-OPERATOR" : _ <br /> • NAME ADDRESS LICENSE# <br /> John Fisher 1819 Hoyt Ave, Everett, WA 98201 P-02764 <br /> NAME OF ASSISTANTS:`fat leastone required) <br /> NAME ADDRESS AGE <br /> Jim Fisher 17418 W. Lake Goodwin Rd Stanwood 98292 35 <br /> NAME ADDRESS AGE <br /> EXACT LOCATIONOF.PROPOSED DISPLAY-. <br /> LOCATION <br /> Everett Memorial Stadium 3900 Broadway, Everett, WA 98201 <br /> DATE TIME <br /> 2015: 6/19, 6/26, 7/4, 7/17, 7/24, 7/25, 8/7, 8/28 10pm+/-following the baseball games <br /> NUMBERAND'_KINDS OF FIREWORKS-TOBE.DISPLAYED: <br /> (30) Cakes, (50) 1.75" Shells - All items are 1.4G Consumer Grade Fireworks <br /> MANNER&PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Local,Fire Authority) <br /> In our approved magazines <br /> SIG�E OF APPLICANT <br /> FINANCIAL RESPONSIBILM—.. : <br /> BONDING OR INSURANCE COMPANY (Mark One) <br /> Professional Program Insurance Brokerage ® Bond or certificate of insurance attached <br /> ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal <br /> 371 Bel Marin Keys Blvd. Ste. 220 Bond or certificate of insurance shall provide minimum coverage of <br /> Novato, CA 94949 $50,000/$1,000,000 bodily injury liability for each person and event, <br /> respectively,and$25,000 property damage <br /> PART II PERMIT <br /> PERMIT# DATE: <br /> In accordance with the provisions of RCW 70.77 and applicable focal ordinances,this permit is granted to conduct a <br /> fireworks display as per the above application. <br /> NAME: <br /> (Full name of person,firm,or corporation granted permit) <br /> RESTRICTIONS: <br /> Permit not valid without verification of (Signature of Official granting permit) <br /> the appropriate State Fireworks License <br /> (Title) <br /> LICENSE NUMBER: <br /> (Instructions en reverse side) <br /> 3000420-050(RR 02/05) Distribufiol WHITE(Al: Local Fire Authority; YELLOW(IB): Fermi <br />