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<br /> ®e. rows , APPLiCATION DATE OF APPLICATION
<br /> PART I
<br /> FOR PUBLIC FIREWORKS DISPLAY PERMIT 5/18/10
<br /> TO: Governing body of city,town,or county in which display is to be conducted.
<br /> • APPLIcAN l;,,I..... .., t .y.ii ,i•:; . . r
<br /> ,4•: -,t`,;�s .,; , t(S�-;1;:=L'�. ;)i.��.�;rsv; ,•?:rcj'•i,.' ±.J��. !'r.:�.... >�\�!�r.1:'f',a,!.�.:vii-�Sfit�`,�t?'i,' .
<br /> NAME ADDRESS PHONE
<br /> Wolverine West, LLC 4616 25th Ave NE #528 Seattle 98105 206.459.0917
<br /> SPONSOR ADDRESS PHONE
<br /> Everett Aqua Sox 3802 Broadway, Everett, WA 98201 425.258.3673
<br /> Tri`-` 1. is`,>. "rP'q..�:'':t'y •.. ;,•;r+' LcS•: rsr` •{�.t i'..
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<br /> NAME ADDRESS LICENSE#
<br /> John Fisher 1819 Hoyt Ave, Everett, WA 98201 -) P-02764
<br /> l ``• i.S �--'s. ;itFS; 1sy f, .:;;[fa.�:,• i�_#`\sYl%:� F:"
<br /> ASS,IS7'ANX,�,,,.(�}�le;�st giiet'.ecjutred):,�..,..,,__.�,>:�_�..t,,,,.,_.<}...�.Y..�,��;�. . :.,:�;..:;�...,.�;�,,a z........ �.r'
<br /> •
<br /> NAME ADDRESS AGE
<br /> Jim Fisher 17418 W.Lk.Goodwin Rd.Stanwood 98292 30
<br /> NAME ADDRESS AGE
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<br /> sEX OT I..OGATIOKOF.M.00..t?SED'p(.$!WAY• . . :i iz :fy :<�,,. .1.:?.i ,*H-�xia,: > _ .:,;t::..� , ;: .. • •
<br /> LOCATION
<br /> Everett Memorial Stadium 3900 Broadway, Everett, WA 98201
<br /> DATE
<br /> TIME
<br /> , 6/25, 7/2, 7/9, 8/7, 8/20, 9/2
<br /> / 10 :00pm +/-
<br /> .,N. i BERAND•KIND.S;OFsF,IRENUORK ._,Ct.>i5;0l$.PLAY . : '_+vW..d.Z .. ...,. -,.: .
<br /> 20 Multi-Shot Cakes - 34 1.75" Shells •
<br /> •
<br /> .4ANNER.;&_ •P AOI_U.E;STO.RAG:E=p.1410,R TO`01:g.P::AY`401i3jeet-00.1 oua(of;; :oc-:f ife gtfi'Qntjr)
<br /> In our licensed magazines �
<br /> SiGNATIJ OI APPLICANT
<br /> IONIAN OALR flA Statun= .41, ,-r'•.'S ..,.,• !t'= ¢w7�:his<;,=, 5, .•p4.y,•...v.:'1�+f`tc•'cl�.firnyr�.r.G,y,_:I...r3'..._. .._,
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<br /> BONDING OR INSURANCE COMPANY (Mark One)
<br /> Combined Specialties International ® Bond or certificate of insurance attached
<br /> ADDRESS ❑ Bond or certificate of Insurance on tile with State Fire Marshal
<br /> 205 San Marin Dr. Suite 5 Bond or certificate of insurance shall provide minimum coverage of
<br /> $50,0001$1,000,000 bodily injury liability for each person and event,
<br /> Novato, CA 94945 respedilvely,and$25,000 property damage
<br /> J
<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 /> •
<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 Flre Authority; YELLOW(B): Permitee
<br /> 112
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