HomeMy WebLinkAboutAPPLICATION - 05-00378 - BYUI - Fireworks~ CITY QF
7~ s AMERICA'S f°AMILY CUMMUNfrY
05 00378
BYU I - 10/11 /05 Fireworks
PERMIT #:
$50.00 FEE PAID: YES NO PERMIT APPROVED: YES/NO
BY: f~ ~ 1~r ~l l'~. DATE: ~ ~~~ ~
~ ~~ro~ CSnn~cs
t
Owner Information: Parcel Number:
Owner: ~~ ~ N/~/~li lil/~~~~i/ Phone Number:
~~~~~~/lv7/
Owner Mailing Address:~~~/~~ ~~ ~~ r ,~~ ~.-~ 1~ ~~y~~
Property Address: ~f ~ /U ~ ~l''~~~( Cell/Office Number: /~6~ ~~~~
Business Name Where Work Will Be Done: ~~~~
Office Address: ~~ ~~
Office Phone Number: ;~_T/''~~~~ Contact Person: ~ ~~. /~ ~ ntact Phone #: U~
Applicant Information:
Name of Business: (~~ I ~~~' (` ,~~ r~L~/~/%Ej
Address: ~~ ~ /V. ~n~ ~~
Contact PersonC"° li%~~ ~~~ PHONE NUMBER: `~I~CELL # d~~~ ~~5~
~~
Parade Route /Assembly Location:
(Map required for Parades)
Cr
SCHEDULE: TO TIME: / 3l~ ~~I
c. __.
F.
l ~ ~-
A T I N TURE DATE
~......... ................................................ P~f ...~
~~`( Fir-~:~~ L~l~ ~S ~er~rn\~ oar - ~ 2005
1
Permit #
PLEASE CHECKTHE TYPE OF PERMIT(S) YOU ARE APPLYING FOR:
^ Aerosol product manufacturing
List of contents:
^ Combustible dust-producing operations
Location:
Type of dust:
^ Covered mall buildings
Location:
^ Cryogenic fluids
Types:
^ Cutting and welding operations
Location:
^ Dry Cleaning plants
Location:
Types of Chemicals:
^ Exhibits and trade shows
Location:
Type of Fire Extinguishers 8~ Location:
^ Explosives
Location:
Types:
^ Fire hydrants and valves
Locations:
Types:
^ Flammable and combustible liquids
Types:
^ Floor finishing
T pes:
^ Fruit and crop ripening
Locations:
Types:
^ Fumigation and thermal insecticidal
fogging
Locations:
Types:
C~
^ Hazardous materials
Locations:
Types:
^ High-piled storage
Location:
Contents:
^ Hot work operations
Location:
Dates & Times of Operation:
^ HPM facilities
Location:
^ Industrial ovens
Location:
Types:
^ Large capacity battery systems
Location:
Type:
^ Liquidlgas vehicleslequip. in assembly
buildings
Location:
Type:
^ LP gas transportation
Location:
Type:
^ Lumber yardslplants
Location:
^ Magnesium work
Location:
^ Misc. combustible storage
Location:
T e:
^ Open burning
Location:
Time & Date:
^ Open flamesltorches
Location:
Time 8~ Date:
^ Operating amusement buildings
Location:
^ Operating aviation facilities
Location:
^ Operating carnivals or fairs
Location:
Dates & Times:
^ Organic coatings
Types:
^ Places of assembly
Location:
Dates & Times:
^ Private fire hydrants
Lo tion:
Pyrotechnic special effects material (Fire works)
Location:
T pes:
^ Pyroxylin plastics
Types:
^ Refrigeration equipment
T pes:
^ Repair garageslmotor fuel dispensing
Location:
^ Rooftop heliports
Location:
^ Spraying o pping
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:
^ UselStorage of compressed gases
Location:
Types:
^ Waste handling
Types:
^ Wood products
Types:
Additional Information:
1d:F7 MT fX~. TT'I ~. S'7?,I~GiiG ~~'xon om-~ ~.!
ACOR~3 CERTtF E flF LtABtL
PRODUCER (208) 524- 5858 F (208) 522-8049
Egan , Metcalf & Leavitt
3780 N. Yellowstone I~''Y i1~f5Uf~1 E of/o7>
THIS CERTIFICATE iS ISSUED AS A MATTER OF MIFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 2498
Idaho Falls, ID 83403
INSURERS AFFORDING COVERAGE.
NAIC#
INSURED E ite Pyrotechnics, LLC INSURERA National Fire & Marine 20079
217 N 3rd West INSURER e:
Rexburg, ID 83440 INSURER C:
INSURER D:
INSURER E:
C~VFROGFS
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 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.
INSR L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILTTY ~ 72LPE-696611 05/18/2005 05/18/2006 EACH OCCURRENCE $ j 000 ~
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RE 0 $ ZOO ~
CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5
r
A PERSONAL & ADV INJURY $ ], ~ 000 ~
GENERAL AGGREGATE $ 2 ~ ~~ ~
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPJOP AGG $ EJ(CLUD
POLICY ~~ LOC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO
IEa accident) $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED RUTOS
(Per person) $
HIRED AUTOS BODILY INJURY $
NOµOV~D A~~ (Per accident)
PROPERTY DAMAGE
(Per accident) $
GARAGE LUIBILITY AUTO ONLY - EA ACCIDENT $
--
ANY AUfO OTHER THMI EA ACC $
~
AUTO ONLY: AGG $
EXCESSAJMBRELLALWBILRY EACH OCCURRENCE
_
r $ __
OCCUR D CLAIMS MADE AGGREGATE
^ $
DEDUCTIBLE $
RETENTION $ $
WORKERSCOMPENSATONAND
' WCSTATU- OTH-
EMPLOYERS
LIABILITY
ANY PROPRIETORJPARTNER/EXECUiIVE E.L. EACH ACCIDENT $
OFFICERlMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS! VEHK:LES t EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
E: Insureds Operations
CFRTIFI[`eTF 41A1 1'1FR reurcl I eTlnu
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUMG INSURER WILL ENDEAVOR TO MAq.
lO DAYS WRITTEN NOTICE tD THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BYU Idaho BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIAB~ITY
16 E . Main OF ANY KIND UPON THE INSURER, RS AGENTS OR REPRESENTATIVES.
Rexburg, ID 83640 Al7THORREDREPRESENTATNE
~
L ette Fountain LYFOUN '`~~'~~
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ACORD 25 (2001108) ®ACORD CORPORATION 1986