HomeMy WebLinkAboutAPPLICATION - 05-00209 - Fourth of July Fireworks
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q~tSNE~~ ANtERfCA'S FRMfLY CC1~~rVvtltM CY 19 E. Mam ,
Rexburg, Id
www.rexbui
~~OPERATIONAL PERMIT" APPLICATION
OS 00209
Elite Pyrotechnics
$50.00 FEE PAID:~NO PERMIT APPROVED: YES/NO
BY: Cpl ~ DATE: ~ • ~ ~ oS
Owner Informa/ti,~o~/n: Parcel Number:
Owner: ~/vL/ ~~. ~,~~~~~ Phone Number: ~~.~~ S~7
Owner Mailing Address: ~/ / V• ~~Q /i(~ ,~~~~ ~ ~ ~~~~~
Property Address: ~! ~ ~l ~2,0 /!l/= Cell/Office Number: - 7 Q~ J~~~
Business Name Where~-Work Will Be Done: ~L./ ,/ ' f~2f~7~1'~/~,r`C.S
Office Address: ~ / l • YLrV ~/(/r ~-~1) If'~~, _~ ~~~~/~
Office Phone Number: ~~~ ~/~'Y~ Contact Perso~ / ontact Phone #: ~f~ r~
Applicant Information: ~~/,~ ~ , ~'~l/~~
Name:
Name of Busin
Contact Person: ~ /!V/ ~-(J ~~ PHONE NUMBER: ® ~S~ELL #
~`~~~~7L ~D13E~,7' Of~7viri~' ~S~`~~/
Parade Route /Assembly Location:
(Map required for Parades)
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~~~
A IC SIGNATURE D E
L
1
^ Operating aviation facilities
Location:
^ Operating carnivals or fairs
Location:
Dates ~ Times:
^ Organic coatings
Types:
^ ..Places of assembly
Location:
Dates 8~ Times:
^ Private fire hydrants
Lo ion:
Pyrotechnic special effects material
Location:
Types:
^ Pyroxylin plastics
T pes:
^ Refrigeration equipment
Types:
^ Repair garages/motor fuel dispensing
Location:
^ Rooftop heliports
Location:
^ Spraying o ping
Location:
^ Storage of combustible fibers
Location:
Types:
^ Storage of scrap tiresletc.
Location:
^ Temp. membrane structures, tents, and
canopies
Location:
Date & Times:
^ Tire-rebuilding plants
Location:
^ Use/Storage of compressed gases
Location:
Types:
^ Waste handling
Types:
^ Wood products
Types:
Additional Information:
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QCORD CERTIFI E OF LIABIL ITY INSURA E o~/3o/Moos'
PRODUCER (208) 524-5858 FAX (208) 522-8049 THIS CERTIFICATE IS I LIED AS A MATTER OF INFORMATION
Egan, Metcalf & leavi tt
3780 N. Yellowstone ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOE8 NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 2498
Idaho Falls, ID 83403 INSURERS AFFORDING COVERAGE NAIL #
INSURED Elite Pyrotechnics, LLC INSLg2ERA: National Fire & Marine 20079
217 N 3rd West INSlA2ER B:
Rexburg, ID 83440 INSURER C:
INSURER D:
INSlB2ER E:
THE POLICIES OF INSURANCE L15TED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MJ~ ~' TYPE OF II~URANCE POLICY NUMBER POLICY EFFECTIVE POLICY TtON LIMITS
GENERALLIAB~rrY T2LPE-696611 05/18/2005 05/18/2006 EACH OCCURRENCE $ 1,~0,
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100 ~
CLAIMS MADE a OCCUR MED EXP (Any one person) $ rj ~
A PERSONAL & ADV INJURY $ 1 ~~ ~
GENERAL AGGREGATE $ 2000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ EXCLUD
POLICY ~~ LOC
AUT OMOBILE LU16R.ITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea ecadert)
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY $
NpN.OWNEp AUTOS (Per accident)
PROPERTY DAMAGE
P
id
t $
(
er acc
en
)
GARAGE LVIBII.RY AUTO ONLY - EA ACCIDENT S
'~ AlnO OTHER THAN EA ACC $
AUTO OILY: AGG $
EXCESSAAIB~.LAIIABILITY EACH OCClA2RENCE $
OCCUR a CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE
RETENTION $ $
WORKERS COMPENSATION AND
EMPLOYERS' LWBS
ITY WC STATU- OTH•
.
ANY PROPRIETORlPARTNER/EXECLRIVE
E.L. EACH ACGDENi ---
$
OFFICERRv1EkffiER EXCLUDED?
If yes
describe older E.L. DISEASE- EAEMPLOYEE $
,
SPECLAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $
OTHER
OESCREn10N OF OPERATXXYS! LOCATXNJS! VEHICLES ! EXCLUSIONS ADDED BY ENDORSEMENT J SPECIAL PROVI~ONS
City of Rexurg
19 East Main
Rexburg, ID 83440
SHOULD ANY ~ THE ABOVE DESCRIED POLICIES BE CANCELLED BEFORE T1iE
EXPIRATION DATE THEREOF, THE ISSUNG MLSURER WILL ENDEAVOR TO MAL
lO DAYS WRII7EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAY.IJRE TO MALI. SUCH NOTICE SHALL S~IPOSE NO OBLATION OR LIABILITY
OF ANY KIND UPON THE INSURER, tf3 AGENTS OR REPRESENTATIVES.
Aun awa:D REPRESENraTIVE
Eric Gessel -New/EBG ~.«= ~J~'
ACORD ZS (2001/08) r~ ~ 3 Sy- st4U ®ACORD CORPORATION 1986
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0500209
Elite Pyrotechnics
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