HomeMy WebLinkAboutAPPLICATION - 06-00332 - BYUI - Spirit Week Fireworks__
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19 E. Main O J o o J
Rexburg, Ic 6
www.rexbu
OPERATIONAL PERMIT" APPLICATION BYUI Spirit Week Fireworks
$50.00 FEE PAID YE /NO PERMIT APPROVED: YES/NO
BY~~__ DATE: _
Owner Information: Parcel Number:
Owner: \ 0~~5~~ j~/~ ~ Phone Number: ~~®~ ~~/ sb
Owner Mailing Address: ~ ~ ~ /V~ c~i2~ (~~ ~~'~U~~ ~Q ~~77~
Property Address: Cell/Office Number:,
Business Name Where Work Will Be
Office Address:
Office Phone Number: ~~~~/~`~'~ Contact Perso lli ,Contact Phone #: T~~~~J
Applicant Information:
Name: ~) ~~ ~~!/~,rl
Name of Business:. ~~ ~ ~ ~~,~s~G~~O~S
Address: ~/ / V , c//~`®~/(/~ /,~(O,_~~/1[S (1~'(C~ J~2 -~C.J ,
Contact Person: t~ !~`~- (/L~ PHONE NUMBER: ~~ ~J~,~~ELL #
Parade Route /Assembly Location: ~"~~~ / /
(Map required for Parades) ~ . ~-~~,T ~~-K ~~~-~ j
SCHEDULE: ~ ~ / TO TIME: T ~~
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~~ ~ VU ~ ~ U
AP A IGNATURE DATE
CI~~'YOF REXBURC
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 & Location:
^ Explosives
Location:
Types:
^ Fire hydrants and valves
Locations:
Types:
^ Flammable and combustible liquids
Types:
^ Floor finishing
Types:
^ Fruit and crop ripening
Locations:
T pes:
^ Fumigation and thermal insecticidal
fogging
Locations:
Types:
^ 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:
^ Liquid/gas vehicles/equip. in assembly
buildings
Location:
Type:
^ LP gas transportation
Location:
Type:
^ Lumber yards/plants
Location:
^ Magnesium work
Location:
^ Misc. combustible storage
Location:
T pe:
^ 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
Pyrotechnic special effects material
Location:
Types:
^ Pyroxylin plastics
T pes:
^ 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 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:
1~:SS TI IN ?F.. ?I,IGt~ TGI Nft. ~'.~~~GflA4 ikAG'~f.11 C>Of'C~ 'OiA
ACO$D~. CERTIFIC OF LIABILITY INSURA 06/26/2006
PRODUCER (208) 524- 5858 FAX (208) 522-8049
Egan, Metcalf & Leavitt
3780 N. Yellowstone THIS CERTIFICATE IS IS ED AS A MATTER OF INFORMATION
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 Elite Pyrotechnics, LLC INSURER A: NatlOnal Fire & Marine 20079
217 N 3rd West INSURER B
Rexburg, ID 83440 INSURER C:
INSURER D:
INSURER E:
COVERAGES
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 EFFECTNE POLICY EXPIRATION LIMBS
GENERAL LIaBq.m 72LPE-696611 05/30/2006 05/30/2007 EACH OCCURRENCE $ 1 ~ 000 ~
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEp $ 100 ~
CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5
A PERSONAL & ADV INJURY $ 1 ~ 000 ~
GENERAL AGGREGATE $ 2 ~ 000 ~
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPfOP AGG $ EXCLIID
POLICY )PERT LOC
AUT OMOBILE LU183.I1Y
COMBINED SINGLE LIMIT
$
ANY AUTO (Ea acciderd)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY
$
NON OWNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident) $
GARAGE LU161LRY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THMI EA ACC $
AUfO ONLY: AGG $
EXCESSRIMBRELLALW86 TY EACH OCCURRENCE $
OCCUR ~ CU VIS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND
' WC STATLL OTH-
EMPLOYERS
LWBILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS! VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECUiL PROVISIONS
ertificate Holder & BYU Idaho is listed as additional insured
m y 12, 2006
l`PRTIPIR,DTF 41A1 flFR re~lrel I eTlnul
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATON DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Madison High School BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LU1BILfiY
290 N. 1st East OF ANY KIND UPON THE INSURER, TIS AGENTS OR REPRESENTATIVES.
Rexburg, ID 83400 AUTHORIZEDREPRESENTATNE ~y
,,,~,,,
Jaime Bradle JB `'~ `""'W
ACORD 25 (2001!08) ®ACORD CORPORATION 1988