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PART I WWASNHINGMN°®� APPLICATION DATE OF APPLICATION <br /> FOR PUBLIC FIREWORKS DISPLAY PERMIT 3/23/23 <br /> TO: Governing body of city,town, or coun in which display is to be conducted. <br /> NAME ADDRESS PHONE <br /> Wolverine West Fireworks PO Box 628-Chehalis,WA 98532 206.459.0917 <br /> SPONSOR ADDRESS PHONE <br /> Everett AquaSox 3900 Broadway Ave, Everett,WA 98201 425.258.3673 <br /> Y �ri 'a. �. i_ r ,h,7 �illd`Ii ii7�g41iiI <br /> NAME ADDRESS LICENSE# <br /> Darik Nelson 1422 85th Drive NE, Lake Stevens,WA 98258 P-04495 <br /> � E OF -eastA � <br /> re <br /> a ,kVl,ll' <br /> NAME ADDRESS AGE <br /> Joshua Krause 9701 21 st Dr SW, Everett WA 98204 36 <br /> NAME ADDRESS AGE <br /> _ Ltd <br /> LOCATION <br /> Memorial Stadium, Everett,WA <br /> DATE TIME <br /> 2023:4/7,5/20,6/3,6/10, 7/2,7/3, 7/22,8/5, 8/19^ 10:00 m+/-followingbaseball games <br /> -,,i. `�t�F FIREWORI�CS t�;)3E DISP YIrD {im„ ilil�() '.4` i� I�IIII�I�Ilipii <br /> All items 1.4G fireworks Not to exceed; <br /> [5011.75"shells- [35] multi-shot cakes <br /> - ) E - pvr Loat 1"i — IIIx <br /> In our magazine gum V_ <br /> SIGNATUIRE OF APPLICANT <br /> 77777 <br /> _ w � , <br /> , ,- �rai�s, �, `,��., U i'I) !1,, ! <br /> A <br /> BONDING OR INSURANCE COMPANY (Mark One) <br /> The Partners GroupX❑ Bond or certificate of insurance attached <br /> ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal <br /> 11225 SE 6th St.,Suite 110 Bond or certificate of insurance shall provide minimum coverage of <br /> Bellevue,WA 98004 $50,000/$1,000,000 bodily injury liability for each person and event, <br /> respectively,and$25,000 property damage <br /> Permit #: FPYR02303-001 <br /> PART II Site Address: 3900 Broadway Ave <br /> PERMIT# Applicant: Rod Hash <br /> In accordance with the provisions of RCW 70.77 a Application Date: 3/24/2023 <br /> fireworks display as per the above application. Description: AquaSox 2023 Season Fireworks <br /> NAME: Review Status: Review by Everett Fire <br /> (Full name of <br /> RESTRICTIONS: Review Date: 4/03/2023 <br /> EVERETT EVERETT <br /> Permit not valid without verification of (Signature -•• _ • <br /> the appropriate State Fireworks License Everett Fire Dept. Permit Review <br /> Status: Approved <br /> Reviewed By: KBrown <br /> LICENSE NUMBER: 04/03/2023 10:41:35 <br /> (Instructions on reverse side) AM <br /> 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee <br />