Laserfiche WebLink
THIS FORM IS INTENDED TO BE USED AS A GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING q <br /> JURISDICTION AND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON <br /> WASHINGTON STATE <br /> PUBLIC FIREWORKS DISPLAY PERMIT <br /> Applican <br /> t . <br /> Name of Event Everett July Fourth <br /> Street Address Barge located 850 feet east of Jetty Island <br /> City Everett County Snohomish <br /> Event Date 7/4/15 Event Time Approx. 10:20 ❑AM ❑✓ PM <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 Display 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 <br /> Name of Permitting Official <br /> Title Phone No. <br /> Permit Granted: ❑Yes —I Yes, with Restrictions (see "Notations" below) ❑ No <br /> Restrictions/Notations <br /> Signature of Permitting Official 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 /> 3000;20-050(R 3/13) <br /> 29 <br />