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<br /> El....... I APPLICATION DATE OF APPLICATION
<br /> 5/18/10
<br /> PART I !.' ;.' FOR PUBLIC FIREWORKS DISPLAY PERMIT
<br /> TO: � ✓ IT in which display Is to be conducted.
<br /> Governing body of city,town,or county p
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<br /> •.APPLiCAN;t s.,.,,.. •iI-, - : . 1�•.'M� is 'k't�'..• - ..-.•.rIS•:.,iS7i.' .,,t�+.:; QTc t1•,:>n'Kr?'ilt'PHONE ,
<br /> �s.•I4;;-'A.,A:, :�iL'�t7;+lh.t'5�..�; �Ir;;....<,-:,fr'.'.c
<br /> NAME ADDRESS
<br /> Wolverine West, LLC 4616 25th. Ave NE #528 Seattle 98105 22H6i.459 .0917
<br /> SPONSOR ADDRESS 425.258.3673PE
<br /> Everett Aqua Sox 3802 Broadway, Everett, WA 98201
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<br /> PYRQT,EGHNIO`,OPERMOR'` 'J'.,::'1.,..: s:' � ''>;:, ; ,.,a:l,.,� .,:..
<br /> NAME ADDRESS LICENSE#
<br /> John f 1819 Hoyt verettt WA 98201 P-02764
<br /> Fisher Ave,� ,:, .-_ „�-._�.'{;���-- •r. ,;:s;::. •+..
<br /> .NAMj~'O ASSISTANTS 1 .l. ';i aui 'toRA ` '� ` M�' ';•�`�-- ,.%.1,.=I-.;4 �,��$�,i:,;�•'
<br /> �.L�St�011 � !'E .:: la�T,'L{-:� r. Y,. r;-.r--.,.s':•...,J''"'..�:.�'--:..
<br /> NAME ADDRESS AGE
<br /> Jim Fisher 17418 W.Lk.Goodwin Rd.Stanwood 98292 AGE30
<br /> NAME ADDRESS
<br /> �y ryn o- ,,,.oi. :.,,.::..-�l_�.�v.} �,.p': `.•�,•.••t�•t�YSi f`' • <�q":�.t:--a rF
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<br /> LOCATION
<br /> Everett Memorial Stadium 3900 Broadway, Everett, WA 98201
<br /> DATE S:OTIME
<br /> 7/3/10 10 .00pm }
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<br /> � �� � �Sr' % ;'41 i- _
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<br /> 34 Multi-Shot. Cakes - 64 1.75" Shells
<br /> ANNE F? d1;Q,K.SIV iGSPRiq. T9'•QiSP1:01 1514¢Ufa:appi0afgrocal,'1=ti'e'Qi(tllo0107
<br /> In our licensed magazines
<br /> s.i,f'• ss.. E1SIGNATUOP APPLICANT
<br /> 40NPNGIgL $00j(jPo�;Y ,. �.0 i.•_ w3 � ti3` , av:k !e,az .t1asi'!. VV:E;.: • . , . ..i3
<br /> {.�
<br /> BONDING OR INSURANCE COMPANY (Mark One)
<br /> ® Bond or certificate of insurance attached
<br /> Combined ADDRESS Specialties International El Bond or certificate of insurance on file with State Fire Marshal
<br /> Bond or certificate of insurance shall provide minimum coverage of
<br /> 205 San Marin Dr.. Suite 5 $50,0001$1,000,000 bodily Injury liability for each person and event,
<br /> Novato, CA 94945 respectively,and$25,000 property damage
<br /> •
<br /> (PART II 1 PERMIT
<br /> PERMIT it 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 I
<br /> (Sig
<br /> I the appropriate State Fireworks License (Stgnalure,of Official granting permit)
<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 /> 115 •
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