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Home My WebLink AboutAPPLICATION - 07-00331 - Elite Pyrotechnics - Fireworks Show"OPERATIONAL PERMIT" APPLICATION n IT #: $50.00 F k YES/ PERMIT APPROVE P: YES /NO 0 BY: ATE: Owner Information: Parcel Number: Owner: Owner Mailing Address: Property Address: Business Name Where Work Will Be Office Address: Number: Cell /Office Number: Office Phone Number: Contact Person: Contact Phone #: Applicant Information: Name: e L/ iE — - `L /ti/; Z /.J& Name of Business: � L-/ TE l�yZd 7r r"'IlVfe ' L �" Address: Z / 7 IV, —y Contact Person: <)ryZ 4 101,P r- PHONE NUMBER: CELL # Parade Route /Assembly Location: (Map required for Parades) TO TIME_ LJ J U L 2 7 2007 1 ZAZ Z&/° ° 7 CITY OF REXBURG APPLICANTS ATURE DAT 1 9 E. Main St. Phone: 208 - 359 -3020 x322 Rexburg, Idaho 83440 Fax: 208 - 359 -3024 www.rexbur-g.org cdd @rexburg.org 0 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: Type: ❑ Open burning Location: Time & Date: ❑ Open flames /torches Location: Time & Date. ❑ Operating amusement buildings Location: Ah ❑ Operating aviation facilities Location: ❑ Operating carnivals or fairs Location: Dates & Times: ❑ Organic coatings Types: ❑ Places of assembly Location: Dates & Times: ❑ Private fire hydrants Lo ion: Pyrotechnic special effects material Location: Types: ❑ Pyroxylin plastics Types: ❑ Refrigeration equipment Types: ❑ Repair garages /motor fuel dispensing Location: ❑ Rooftop heliports Location: ❑ Spraying or ipping 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: Additional Information: /mot/ 'q /t 1t''C' 7z) ACORD. CERTIFICAT&OF LIABILITY 1NSURAN DATE (MMIDDVYYYY) INSR ADM TYPE OF INSURANCE 07/25/2007 PRODUCER (208) S24 -5858 FAX (M)522-9049 THIS CERTIFICATE IS ISSND AS A MATTER OF INFORMATION Egan, Metcalf & Leavitt ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 72LPSOOS3$4 06/05/2007 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3780 N. Yellowstone $ 1,000 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 2498 Idaho Falls, ID 83403 $ 100.00 INSURERS AFFORDING COVERAGE NAIL # INSURED Elite Pyrotechnics, LLC INSu1ERA National Fire & Marine 20079 217 N 3rd West $ 5,00 INSURER& Scottsdale Insurance Company 41297 Rexburg, ID 83440 INSURER C: INSURER O: INSURER E: rnVC0Ar_Cc 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 ADM TYPE OF INSURANCE POLICY N UMBER POLICY EFFECTIVE POLICY EXPIPATM LIMITS GENERAL LIABILITY 72LPSOOS3$4 06/05/2007 06/05/2008 EACHOCCURRENCE $ 1,000 X COMMERCIAL GENERAL DAMAGE To TENTED - $ 100.00 CLAIMS MADE 1 X I OCCUR �,...� MED EXP ICY one Pte) $ 5,00 PERSONA- & AM INJURY $ 1, A GENERAL AGGREGATE S 2 , 000 , 00 GENL AGGREGATE LIMIT APPLES PER: PRODUCTS - COMPIOP AGG $ EXCLUDE POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ; AN AWO (Ea accidetd) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per Person) BODILY INJURY S HIR€D AUTOS NON- OYYNED AUTOS (PeracadeM) PROPERTY DAMAGE {Per ac(d) : GARAGE LIABILITY AUTO ONLY - EA ACCIDENT i OTHER THAN EA ADC S ANY AuTG $ MIfOONLY: AGG EXCESSIUMBRELLA LIABILITY TBD 06/05/2007 06/05/2008 EACH OCCURRENCE $ 2,00-0,00 - X j OCCUR a CLAMS MADE AGGREGATE $ B 2000000 $ 2,000,00 $ DEDUCTIBLE $ X RETENTION S 10, WC OTH- STATt} WORKERS COMPENSATION AND E.L. EACH ACCIDENT S EMPLOYERS' LIABILITY ANY PROPRETOR/PARTNERIEXECUTIVE E.L. DISEASE - EA EMPLOYEE S OFFICERNIEMBER EXCLUDED? If yes. describe raider SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT S OTHER C r E E-9111� DESCRIPTION OF OPERATIONS H LOCATIM4 H VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT) SPECIAL PROVISIONS ity of Rexburg, BYU Idaho, & Internatonal Fok & Dance Music Festival i i ed a s additional insured in regards to show on 07 -23 -2007 JUL 2 7 2007 CITY OF R BUR Rexburg Chamber of Commerce 12 N. Center Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING WSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KWD UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Jaime Bradley /JB e! " ACORD 25 (2001/06) MACORD CORPORATION 1988