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HomeMy WebLinkAboutAPPLICATION - 05-00218 - BYUI - Fireworks• _ ~ ~~~.~ GITY OF ~~'p~~1SHEd''~ AMERfCA'S FRlltifLY CC?xbiNtUMTy 19 E. Main St. Phone: 208-359-3020 x322 Rexburg, Idaho 83440 Fax: 208-359-3024 www. rexburp. orp cdd@rexburg.org "OPERATIONAL PERMIT" APPLICATION ..A-~mS~ b~A~ PERMIT #: ~ ~ 000(Q3 $50.00 FEE AI YES 0 PERMIT APPROVED/NO BY: DATE: ~ ~ ~ ©`~ Owner: Phone Number: Owner Mailing Address: Property Address: Cell/Office Number/: ' ~~ ~,/ Business Name Where Work Will Be Done: L~7U.~ ~iZLYT/~ f~/~~ ~~if!/NC1 ,~,~~~~j~ Office Address: Office Phone Number: Contact Person: Contact Phone #: Applicant Information: Name: ~L~~ ~ / ~/~/~j i/ /~ Name of Business: 2~~" ~~ ~~"" ~~ Address: 2/ 7 /V ~4U v1/• Contact Person:~~~~ ~~~~ PHONE NUMBER: c3~~CELL # Parade Route /Assembly Location: (Map required``fo~~r Parades) SCHEDULE: ~i 7 ~ f ~l -l1 S TO TIME: l ~'. ~ ~ ~ [~'. 3D _7 AP NATUR D E 1 ^ Operating aviation facilities Location: ^ Operating carnivals or fairs Location: Dates & Times: ^ Organic coatings Types: ^ .Places of assembly Location: Dates 8~ Times: ^ Private fire hydrants Location: Pyrotechnic special effects material Location: T pes: ^ Pyroxylin plastics Types: ^ Refrigeration equipment T pes: ^ Repair garages/motor fuel dispensing Location: ^ Rooftop heliports Location: ^ Spraying or ipping Location: ^ Storage of combustible fibers Location: Types: ^ Storage of scrap tiresletc. Location: ^ Temp. membrane structures, tents, and canopies Location: Date & Times: ^ Tire-rebuilding plants Location: ^ Use/Storage of compressed gases Location: T pes: ^ Waste handling Types: ^ Wood products Types: Additional Information: ~~$L~ CERTifiC t3f LIABILITY IN " ~°°~ „ SURAN oi~o7 ~2 oos PROa~cER (208) 524- 5858 FAX ) 522-8049 THIS CERTIFKATE IS ISSUED AS A MATTER OF INFORMATION Egan, Mettal f & Leavitt ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE 3780 N. Yellowstone PO Box 2498 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIClE3 BELOW. Idaho Falls, ID 83403 INSURERS AFFORDING COVERAfs6~~- NAIL # InsuR®E ite Pyrotechnics, LLC INSURER A: National Fire & Marine 20079 217 N 3rd 14est INSURER B: Rexburg, ID 83440 INSURER C: INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 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 LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. BIER .L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LMtli3 SAL LIAB~rTY 72LPE-696611 05/18/2005 05/18/2006 EACH OCCURRENCE $ 1,000, X CObwv1ERCIAL GENERA!. LIABILITY DAMAGE TO RENTED RFS„(Fa ncniranr 1 _ $ 100 CLAIMS M+xDE ~ OCCUR MED EXP (Any one person} ; 5 A PERSONAL 8 ADV INJURY $ 1 ~~ GENERAL AGGREGATE ~ ~ $ 2 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COA1P/OP AGG ~ ~ ; ~(CL(~ PGLICY ~T LOC AUT OMOBILE LU161LITY COMBINED SINGLE LIMIT ; ANY AUTO (Ee accidert} ALL OWNED AUTOS BODILY INJURY ~ SCHEDULED AUTOS (Per person} HIRED AUTOS BODILY INJURY ; NON-OWNED AUTOS leer ecadeM) PROPERTY DAMAGE P ; ( er accident) GARAGE LIAB~ITY AUTO ONLY - EA ACCIDENT $ ~'~O OTF~R 11-WN EA ACC ; AUTO ONLY: AGG $ EXCESSAAiBRELLA LIABILITY EACH OCCURRENCE ; OCCUR ~ CLAIMS MADE AGGREGATE ; $ DEDUCTIBLE RETENTION $ ; WORKERS COMPENSATION AND WC STATLL OTH- EMPLOYERS' LWBILTTY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If yes describe urxler E.L. DISEASE - EA EMPLOYEE ; , SPECIAL PROVISIONS beloN E.L. DISEASE -POLICY LIMIT ; OTifR DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHCLES I EXCLUSXNJS ADDED BY EPS)ORSENENTI SPECIAL PROVISIONS E: Insureds Operations 8YU Idaho 16 E. Main Rexburg, ID 83640 MOULD ANY OF THE ABOVE DESCRE<ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUMG INSURER WILL ENDEAVOR TO MAT. lO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMEb TO THE LEFT, BUi FAKURE TO MAIL SUCH NOTICE SHALL MIPOSE NO LIGATION OR LU1BlITY OF ANY KIND UPON THE INSURER, IT'S AGENTS OR REPRESENTATNES. AUTHORI>~DREPRESENTATIVE /~.~~~ Jaime Bradley/]B `~"`"""`~ AcoRO zs (zoo7ro6) ®ACORD CORPORATION 1866