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❑❑s APPLICATION DATE OF APPLICATION <br /> PART I w" FOR PUBLIC FIREWORKS DISPLAY PERMIT JO '- -'d.g <br /> TO: Governin• bodof cit , town,:or count in which dis•la is to be conducted. <br /> ga <br /> ADDRESS ! PHONE illeFRRMR <br /> 92 <br /> SPONSORADDRESS <br /> 7 <br /> .ADDRESS J - <br /> L 'kloi a 113NAMI <br /> 1 F a <br /> ADDRESS <br /> 77- <br /> MIrd,.. I_- r ,.r i ..I aha ;f.M <br /> galill <br /> NAME ADDRESS AGE <br /> Z E lac c p;c <br /> LOCATION <br /> �.x,. s�� .�L yam;/ ': <br /> DATE TIM p <br /> l0 0 : ?,'Gr) <br /> _ O se/... II <br /> • <br /> `r!�!I`,;l �¢7'rr k l�Ci rCir fL ti� R{12, l _ � `'t i �hf ;' 6.7§ A Iisa /A(1,ridf ¢,' 1' <br /> �,.: AAY;tJFLnE 1@c"it" ,.,e.Pr- L1rr:_ �_. a_�..._.�.�__.�._nF,...a:ai 7r �a.�..- a,l�'_' . ._`-___�� ....,,.�.,.,� <br /> BOM .O Q/ URfCQMPANYY (Mark One) <br /> COKS � C/4/+li&S <br /> - t Q'Bond or certificate of insurance attached <br /> ADDRESS Q2/ g �►�fyjpt �' vj GE Z Bond or certificate of insurance on file with State Fire Marshal <br /> Bond or certificate of insurance shall provide minimum coverage of <br /> £7 r' 'I P-. $50;000/$1 000;000 bodily injury liability for each person and event, <br /> q {�occ)b uk)'l 14 A�` c� l,I( respectively,and$25;000 property damage <br /> PART n 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 /> 1.C3 (Title). <br /> LICENSE NUMBER: t � 0 136, 0 <br /> (Instructions on reverse side) <br /> 3000-420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee <br />