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PWWASNHN <br /> INGM° <br /> ARTIU� APPLICATION DATE OF APPLICATION <br /> it FOR PUBLIC FIREWORKS DISPLAY PERMIT 3/23/23 <br /> TO: Governing body of city,town, or county in which display is to be conducted. <br /> APIP <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 91ii 7 �illd`Ii ii7��41iiI 2 <br /> NAME ADDRESS LICENSE# <br /> Darik Nelson 1422 85th Drive NE, Lake Stevens,WA 98258 P-04495 <br /> � EOFA <br /> t a ,kVl,ll' <br /> NAME ADDRESS AGE <br /> Joshua Krause 9701 21 st Dr SW, Everett WA 98204 36 <br /> NAME ADDRESS AGE <br /> E12"! 1111,111L <br /> T, SPILA <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 FIREWC?RFC "I'll.BE DISP YED <br /> All items 1.4G fireworks Not to exceed; <br /> [5011.75"shells- [35] multi-shot cakes <br /> - ) EpLoa fire — x <br /> In our magazinegum <br /> _ <br /> //�7 SIGNATU E O''''F APPLICANT <br /> � , ::, lRI ter_—;',i tl GI ��) ((tl�li �� ii u�-„' IMF <br /> i`r k � � <br /> BONDING OR INSURANCE COMPANY (Mark One) <br /> The Partners Group © 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 /> PART II 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 /> (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 on reverse side) <br /> 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee <br />