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� 3 <br /> ®1®l cm®® APPLICATION DATE OF APPLICATION <br /> PART I FOR PUBLIC FIREWORKS DISPLAY PERMIT 8/26/11 <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, LLC PO Box 99095 Seattle, WA 98139 206 .459 . 0917 <br /> SPONSOR ADDRESS PHONE <br /> Henry Jackson HS 1508 136th St SE Mill Creek WA 98012 425 . 385 . 7105 <br /> PYROTECHNICOPERATOR <br /> NAME ADDRESS LICENSE# <br /> Andy Mihalyi 11525 Littlerock Rd Oly. WA 98512 P-04256 <br /> 'NAME OF AS STANTS._AM least one regafned) <br /> NAME ADDRESS AGE <br /> Rod Hash PO Box 99095 Seattle, WA 98139 42 <br /> NAME ADDRESS AGE <br /> EXACT LOCATION OF PROPOSED DISPLAY <br /> LOCATION <br /> Memorial Stadium Practice Field, Everett, WA <br /> DATE9/30/11 TIME 8 :3 0pm +/- <br /> NUMBER4D3 KINDS OF FIREINt)RI S'TO BE DISPLAYED <br /> (30) 1 .4G Multi-Shot Cakes - (64) 1 .4G 1 . 75" Shells <br /> MANNER PLACE OF STORAGEPRII'R TO DlSPLAYIS 7e to appravai of0Ozil fire Authority) <br /> In our licensed magazines4� <br /> SIGNATU= OP APPLICANT <br /> FetANtiALRESPONSISILITY , <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 file with State Fire Marshal <br /> 205 San Marin Dr. Suite 5 Bond or certificate of insurance shall provide minimum coverage of <br /> $50,000/$1,000,000 bodily injury liability for each person and event, <br /> Novato, CA 94945 respectively,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 /> 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 /> 9 6 <br />