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HomeMy WebLinkAboutAPPLICATION & INSURANCE - 07-00484 - BYUI - FireworksOperational /Fireworks Display ��EXBVR� Permit Application 19 East Main City of Rexburg Rexburg, ID 83440 www.rexburg.org Phone: 208.359.3020 Fax: 208.359.3024 C I T Y OF REXB America's Family Community rmit #: $50.00 FEE P ID- NO PERMIT APPROVED: /NO BY: ATE: 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: EL TE PMT �WN /6 1 j L Contact Person: Contact Telephoj Name of Organization Applicant Represents: sy(J --bp"1 n Proposed Date and Time of Display: Rain Date: Name of Person Conducting Display: 120Y QgIZ }- '11 f j /alt/ P /a� (Please provide copy of State licenses) Type, Size and amount of fireworks to be discharged: TD Storage location of fireworks: (�ax L u p 6 Exact location of display: !F l 7%7t 5? � Um, /Zl� ^ 7.�/ r� � ��-</ /k �L j (Please provide a map of the area) Owner of property where display is to be located: ST L _2..D Phone: Liability insurance covering event: (attach copy of policy) Company: Coverage Period: Name of nt: Policy #: Policy Limits: _ Agent Phone #: Signature of Cod fficial Verifying Coverage Name of Insurance Co. Representative Providing Information 0 0 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 P) v 0 Consent of Property Owner 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 Printed Name Address: 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 minim of two (2) 2A1013C 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 Signature Applicant Check List This form filled out in its entirety Certificate of Insurance Payment of permit fee 9Z T ,! .7 Date Copy of State License Detailed site plan Consent of property owner 3 ACORD CERTIFICA PROD UCER (208) 524 -5858 FAX ( Egan, Metcalf & Leavitt OF LIABILITY INSURA E /D 09/28 09 /28/22Q07 007) ) 522 -8049 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 3780 N. Yellowstone PO Box 2498 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Idaho Falls, ID 83403 INSURERS AFFORDING COVERAGE NAIC # INSURED Elite Pyrotechnics, LLC 217 N 3rd West Rexburg, ID 83440 LIMITS INSURERA: National Fire & Marine 20079 INSURERB: Scottsdale Insurance Company 41297 INSURER C: 06/05/2007 06/05/2008 EACH OCCURRENCE INSURER D: X DAMAGE TO RENTED $ 100,000 INSURER E: MED EXP (Any one person) .0 V tKAlat1 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. I R DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MIWDD/YY) POLICY EXPIRATION DATE (MM/DDNYI LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE FX OCCUR 72 LPS005384 06/05/2007 06/05/2008 EACH OCCURRENCE $ 11000.000 X DAMAGE TO RENTED $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1 000 000 GENERAL AGGREGATE 1 1 $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT M LOC PRODUCTS - COMP /OP AGG $ EXCLUDE AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ B EXCESS /UMBRELLA LIABILITY X OCCUR CLAIMS MADE ] DEDUCTIBLE F x RETENTION $ 10,00 TBD 06/05/2007 06/05/2008 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2000000 $ 2,000,000 $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below WC STATU- OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS YU Idaho & City of Rexburg is listed as additional insured in regards to show: ctober 9, 2007 BYU Idaho 525 S. Center Rexburg, ID 83460 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 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 UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Jaime Bradle /]B AI:UKU Zb ( /U8) rmn: ©ACORD CORPORATION 1988