HomeMy WebLinkAboutALL DOCS - 06-00331 - 4th of July Fireworks PermitZ ~ ~ 11 Z - ysa CjTrO
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~~~'~°,~~ CITY QF
~`~q$~~N~+.`~` AMERICA'S FAMILY CQM:4IUNITY 19 E. Main St.
Rexburg, Idaho 06 00331
www. rexburg.or
"OPERATIONAL PERMIT" APPLICATION
July 4th Fireworks
$50.00 FEE PAI~YEyS~IVO PERMIT APPROVED: YES/NO
Owner Information: Parcel Number:
Owner:_~~ ~ f' L~ Phone Number: ~~~~ Y~~~ ~~~,SL~
Owner Mailing Address: r~~ ~ ~V, C- ~,(l l~(e, ~,~~f ),r~ ~ ~ ~3t,~1~jS
Property Address: Cell/Office Number:
Business Name Where Work Will Be Done:
Office Address:
Office Phone Number: ~~1L~"~XJ~'c~~y~ontact Person: ontact Phone #: ~~~~.3~ii~CJ
Applicant Information:
Name: r f~f~~
Name of Business: ~~ / / E f ~~~ ~' /Uj
Address:~`~ 7 / ~l. ~/Z,~ Li(~ ~~(s~~ .-~'-,~ ~! L~_/~_
Contact Person: ~ ~ ~~~ PHONE NUMBER: - 7~~ ~~%~`~ELL # f / /~
Parade Route /Assembly Location: (,,~1 ~ f ''~~,~ ~~ ~(~~~' ~'l~ ~ f ~" ~//~-
(Map required for Parades) ~~ ~;~~~~s. ~~~ ~~ .~~ ~~~ ~_~,~?~~~
1 f ],`~j,
SCHEDULE: ~J l~ L-~~ ~/ TO t~ ~ ~~
APPLICANTIGPNATITRE DATE
V
...JU19' ~' ~' ~DO~ ~ `
c~~o~~ExeuRo
•
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
Types:
^ Fruit and crop ripening
Locations:
Types:
^ Fumigation and thermal insecticidal
fogging
Locations:
Types:
C~
J
^ 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 vehicles/equip. in assembly
buildings
Location:
T pe:
^ LP gas transportation
Location:
Type:
^ Lumber yards/plants
Location:
^ Magnesium work
Location:
^ Misc. combustible storage
Location:
T e:
^ Open burning
Location:
Time & Date:
^ Open flames/torches
Location:
Time & 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
Loc on:
Pyrotechnic special effects material
Location:
Types:
^ Pyroxylin plastics
Types:
^ Refrigeration equipment
T pes:
^ Repair garages/motor fuel dispensing
Location:
^ Rooftop heliports
Location:
Additional Information:
^ Spraying or ipping
Location;
^ Storage of combustible fibers
Location:
Types:
^ Storage of scrap tires/etc.
Location:
^ Temp. membrane structures, tents, and
canopies
Location:
Date 8~ Times:
^ Tire-rebuilding plants
Location:
^ Use/Storage of compressed gases
Location:
Types:
^ Waste handling
T pes:
^ Wood products
Types:
A 1 F: dR TI IN ?F.. ?GII~
ACORD~, CERTIFIC
OF LIABILITY INSURA °"~`~""°°"""'
06/26/2006
PRODUCER (208) 524- 5858 FAX (208) 522-8049
Egan, Metcalf & Leavitt
3780 N. Yellowstone THIS CERTIFICATE IS ISS ED AS A MATTER OF INFORMATION
ONLYAND 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 Elite Pyrotechnics, LLC INSURER A: NatlOnal Fire & Marine 20079
217 N 3rd West INSURER B:
Rexburg, ID 83440 INSURER C:
INSURER D:
INSURER E:
rnveowr_ec
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 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.
INSR D'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERALLIABILTTY 72LPE-696611 05/30/2006 05/30/2007 EACH OCCURRENCE $ 1,000,
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100 ~
CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5 ~
A PERSONAL & ADV INJURY $ 1 ~ COQ ~
GENERAL AGGREGATE $ 2 ~ 000 ~
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ EXCLUD
POLICY JET LOC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO
{Ea accident) $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS
{Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
P
i $
(
er acc
dent)
GARAGE LIABII.TTY AUTO ONLY - EA ACCIDENT $
ANY AUTO EA ACC
OTHER THAN $
AUTO ONLY: AGG $
EXCESSAJMBRELLALU181L1TY EACH OCCURRENCE $
OCCUR ^ CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND WC STA
TU- OTH-
EMPLOYE
' ~
RS
LWBILTTY
ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
If
es
describe und
r E.L. DISEASE - EA EMPLOYEE $
y
,
e
SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS! VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECULL PROVISIONS
ertificate Holder & Rexburg City of Commerce is listed as additional insured
m y 4, 2006
City of Rexburg
19 East Main
Rexburg, ID 83440
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUWG INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LL4BILRY
OF ANY KIND UPON THE INSURER, RS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATTJE
Jaime Bradley/JB `~ -`~"--
acvRD zs {2001!08) OACORD CORPORATION 1988