HomeMy WebLinkAboutAPPLICATION - 06-00333 - Dance Festival - Fireworksf
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19 E. Main St. ~6 00~ ~ 2
Rexburg, Idaho J
www.rexburg.or
OPERATIONAL PERMIT" APPLICATION Folk Dance Festival Fireworks
$50.00 FEE PAI YES% 0 PERMIT APPROVED: YES/NO
BY: _ _ _ _ -DATE:.
Owner Information: Parcel Number:
Owner: C \ ~` j~/~~~ Phone Number: ~~~ 315~~
Owner Mailing Address:. ~~ ~ / 1~ • ~~~ ~/. ~ j~,f~~ Z~ ~~~~~
Property Address: Cell/Office Number:
Business Name Where Work Will Be Done:
Office Address:
Office Phone Number: ~~/~~~d Contact Person:(_J~~~l~o~ct Phone #: ~~~~ ~l~
Applicant Information:
Name of Business: ~~//~ ~'J~®~tC~~i//lO/~
Address:_~~~ N ~~~ ~~ ~.~i~C ~~L~~ ..._L~
Contact Person: <...JGT ~ ~~~~ PHONE NUMBER: ~~~3~~/~CsCELL # fr ~~
Parade Route /Assembly Location: ~~~~ 15b~ ~1~~/'T cf7~~~~~ ^ ~~~~~~is
(Map required for Parades) ~/,2 ~~~~ 2N7~j1/~}-T/D~U4-L ~~ c; Q,~~;/~,(~.~ ~~/~
SCHEDULE: ~ Il) L / ~ OI~lC~1~ T/ME: %.~~5'~~-l~ _ p/y
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APPLICA IGNATURE DATE
Permit
PLEASE CHECKTHE TYPE OF PERMITS 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:
Types:
^ 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 n:
Pyrotechnic special effects material
Location:
Types:
^ Pyroxylin plastics
Types:
^ Refrigeration equipment
Types:
^ Repair garages/motor fuel dispensing
Location:
^ Rooftop heliports
Location:
Arlrli4inn~l Infnrrr»4inr~•
r-~
^ Spraying or dipping
Location:
^ Storage of combustible fibers
Location:
Types:
^ Storage of scrap tires/etc.
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:
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~~?~~, CERTIFIC OF LIABIL ITY INSURA o~ii ~~ s
PRODUCER (208) 524- 5858 F 208) 522-8049
Egan, Metcalf & Leavi tt
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: National Fire & Marine 20079
217 N 3rd West INSURER B:
Rexburg, ID 83440 INSURERC
INSURER D
INSURER E:
rnvcoer_ca
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 LIMR'S
GENERAL LU181LR1' 72LPE-696611 05/30/2006 05/30/2007 EACH OCCURRENCE $ 1, 000,
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100 ~
CLAIMS MP.DE ~ OCCUR MED EXP (Any one person) $ 5 ~
A PERSONAL 8 ADV INJURY $ 1 ~ 000 ~
GENERAL AGGREGATE $ 2 ~ 000 ~
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ EXC LUD
POLICY JE7 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
(Per accident) $
GARAGE LU181LfTY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER TF{AN FA ACC $
AUTO ONLY: qGG $
EXCESSAIMBRELLALIABILITY EACH OCCURRENCE $
OCCUR ~ CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATIONAND
' WC STATU- OTH-
~
EMPLOYERS
LIABILITY ' -
ANY PROPRIETOR/PARTNERlEXECLITIVE E1. EACH ACCIDEM $
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! VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS
ertificate Holder & Idaho International Folk & Dance Festival is listed as additional insured
m y 29, 2006
Madison High School
290 N. 1st East
Rexburg, ID 83440
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
3O DAYS W WTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO TFIE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, fTS AGENTS OR REPRESENTATIVES.
AlliHOR~D REPRESENTATNE
Jaime Bradley/JB '
ACORD 25 (2001!08) OACORD CORPORATION 1988