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APPLICATION DATE OF APPLICATION <br /> ,r FOR PUBLIC FIREWORKS DISPLAY PERMIT 5/13/16 <br /> TO: Governing body of city, town, or county in which display is to be conducted. <br /> APPLICANT <br /> NAME ADDRESS PHONE <br /> Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 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: (at least one required) <br /> NAME ADDRESS AGE <br /> Jim Fisher 17418 W. Lake Goodwin Rd Stanwood 98292 36 <br /> NAME ADDRESS AGE <br /> EXACT LOCATION OF PROPOSED DISPLAY <br /> LOCATION <br /> Everett Memorial Stadium 3900 Broadway, Everett, WA 98201 <br /> DATE TIME <br /> 2016: 6/24, 7/4, 7/9, 8/5, 8/13, 8/19, 8/27, 9/3 10pm+/- following the baseball games <br /> NUMBER AND KINDS OF FIREWORKS TO BE 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 La <br /> SIGNATU-E OF APPLICANT <br /> FINANCIAL RESPONSIBILITY <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$25,000 property damage <br /> PART II PERMIT <br /> PERMIT# 7.0 1 'U' G 3 DATE: J — J L <br /> In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a <br /> fireworks display as per the above application. <br /> NAME: '(i-$h4! -' J c- <br /> (Full name of person,firm,or corporation granted permit) <br /> RESTRICTIONS: <br /> r;I-N 3-- <br /> Permit not valid without verification of (S nature of 6, ficial granting pe 't) <br /> the appropriate State Fireworks License C, ?F44)f �, / C 'w�l <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 />