The URL can be used to link to this page

Home My WebLink AboutAPPLICATION - 07-00426 - Elite Pyrotechnics - Fireworks• Operational /Fireworks Display � U Q Permit Application 19 East Main City of Rexburg . ;at Rexburg, ID 83440 www.rexburg.org Phone: 208.359.3020 Fax: 208.359.3024 CITY OF REXBURG c l w ___- ..- . - - - -- Americas Family Community Permit #: O �- ) $50.00 FEE PAID, YES) NO PERMIT APPROVED: YES /NO DATE: Application for permit to operate a display of outdoor fireworks in conformance with adopted codes and ordinances of the City of Rexburg shall be made in writing on forms provided by this city. All requested information must be provided, incomplete applications will be denied. This display permit allows the discharge of fireworks by qualified persons only. Completed applications must be received a minim of 7 days prior to the event. Name of Applicant/Company: Contact Person: "LAFF"' Contact Telephone Number: Z Cell: Name of Organization Applicant Represents: Proposed Date and Time of Display: -5l_= �T % Rain Date: Name of Person Conducting Display: J5 M r /i?' L. f /k) (Please provide copy of State licenses) Type, Size and amount of fireworks to be discharged: 'y Lc %�� I Storage location of fireworks: V/4 Exact location of display: A/5 TL, C`�L12L 61 (Please provide a map of the area) 0 Owner of property where display is to be located: ��N+'� /�C >l,' }1-1Z- 11 . %XE ri,yeL: el9yi w Phone: Liability insurance covering event: (attach copy of policy) Company: Coverage Period: Name of Agent: Policy #: Policy Limits: _ Agent Phone #: Signature of Code Official Verifying Coverage Name of Insurance Co. Representative Providing Information SITE PLAN Please provide an accurate drawing of the following items: 1) Fireworks discharge area 2) Distance between discharge area and any structures on or to be placed on property 3) Distance between spectators and discharge area 4) Location of fire safety and first -aid equipment 2 0 Consent of Property Owner 0 I /We , owners of the above described property, hereby expressly give my /our consent to the use of my /our property for the event applied for in this application. Signature of Property Owner Address: Printed Name Telephone: If the display is to take place on property belonging to The Church of Jesus Christ of Latter Day Saints, a letter of authorization from a representative of the church shall be provided with this application. OTHER REQUIREMENTS 1. A minimum of two (2) 2A10BC fire extinguishers shall be present at the site during the fireworks display. 2. A minim of two (2) qualified persons shall supervise the actual firing at all times during the display. 3. A copy of the approved permit must be on -site during the display. 4. If a burn ban or winds exceeding 20 miles per hour exist at the time of the display the show will be cancelled. My signature indicates that I understand and will comply with all requirements to ensure a safe and legal discharge of Signa Z /3r /�J7 Date Applicant Check List This form filled out in its entirety Copy of State License Certificate of Insurance Detailed site plan Payment of permit fee Consent of property owner 3 i ACORP. CERTIFICAO OF LIABILITY INSURA DATE (MMIODNrM 08/24/2007 PRODUCER (209)S24-5858 FAX (208) 522 -8049 Egan, Metcalf & Leavitt 3780 N. Yellowstone PO Box 2498 Idaho Falls, ID 83403 THIS CERTIFICATE IS ISM 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. INSURERS AFFORDING COVERAGE NAIL # INSURED Elite Pyrotechnics, LLC 217 N 3rd West Rexburg, ID 83440 1NSuRERk National Fire & Marine 20079 INSURERS: Scottsdale Insurance Company 41297 INSURER C: 06/05/2007 INSURER 0: EACH NCE INSURER E: 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 ADDI TYPE OF MSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY 72LPSOOS384 06/05/2007 06/0S/2008 EACH NCE $ 1,00 00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00 CLAIMS MAIZE OCCUR HIED EXP (My one person) $ 5,00 PERSONAL & ADV INJURY $ 1 A GENERAL AGGREGATE $ 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG $ EXCLUDE POLICY p jE R C O T LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Es accident) $ BODILY INJURY {Per Person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIREDAIJTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESSM1IMBRELLAI'ABILITY TBD 06/05/2007 06/05/2008 EACH OCCURR $ 2,000,00 AGGREGATE $ X OCCUR CLAIMS MADE 2000000 $ 2,000,00 B $ H DEDUCTIBLE $ X RETENTION $ 10,000 WC DTI+ WORKERS COMPENSATION AND ILIMI E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPRIETOR(PARTNERIEXECUTIVE E.l. DISEASE - EA EMPLOYE $ OFFICERiMEMBER EXCLUDED? If yes. describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 1 $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IEXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Games Madison School District #321 & City of Rexburg PO Box 830 Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 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 KIND IRON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Jaime Bradley/10 ORD 25 (2001108) OACORD CORPORATION 1988