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HomeMy WebLinkAboutALL DOCS - 08-00339 - Relay for Life - Fireworks0 0 Operational /Fireworks Display 0 Permit Application City of Rexburg 19 East Main Phone: 208.359.3020 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 C I T Y OF REX Americas Family Community Per WC�� $50.00 FEE PAID: YE O ERMIT APPROVED: YES /NO �t6 VV `^ r dmj BY: DATE: Z,�,-� - 7 lit /O 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 r a minim of 7 days prior to the event. Name of Applicant /Company: /� / /�(�T %rt� Contact Person: I Contact Telephone Number: 3 59- - Z& 7l Cell: Name of Organization Applicant Represents: Proposed Date and Time of Display: 7/a/14 Rain Date: Name of Person Conducting Display: P 9cArl C /V 4e166N C6yti'TI 4E t (Please provide copy of State licenses) \ Type, Size and amount of fireworks to be discharged: 2,L �� 7 / S - ? ,a A/ Storage location of fireworks: Exact location of display: NxV 914- L (Please provide a map of the area) /� "� Owner of proper where display is to be located: /1460A) SJ7C)OL &5T Phone: Liability insurance covering event: (attach copy of policy) Company: Coverage Period: Name of Agen Si atute of Co e Official Verifying Coverage Policy #: Policy Limits: _ Agent Phone #: Name of Insurance Co. Representative Providing Information 0 , Consent of Property Owner I /We Ma&SM 5UO3 I ' Si �J ?i( , 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. S Signature of PropeRy Owner Printed N Address: Z "1 /� G � vw•� Telephone: ZOr6— 351' 3,3o y 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) 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 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 G fi f L'irf I � I ti �i l�►lGTGT_7 TFI Nil: 522 - RA4C) #87218 PAGE: 1/2 ACORD CERTIFI E OF LIABILITY INSU CE 0f /11 /20 PRODUCER (208) 524 -5858 FAX (208) 522 -8049 Egan, Metcalf & Leavitt 3780 N. Yellowstone PO Box 2498 Idaho Falls, ID 83403 THIS CERTIFICATE IS ISSUED 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 NAIC # INSURED Elite Pyrotechnics, LLC 217 N 3rd West Rexburg, ID 83440 INSURER A: National Fire & Marine 20079 INSURERB Scottsdale Insurance Company 41297 INSURER INSURER D: 72LPS005384 INSURER E 06/05/2009 COVFRAQPS 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 I DD'L NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDD POLICY EXPIRATION DATE MMIDD .LIMITS Rexburg, ID 83440 GENERAL LIABILITY 72LPS005384 06/05/2008 06/05/2009 EACH OCCURRENCE $ 1 , 000,000 X COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENTED $ 100 CLAIMS MADE F x OCCUR ++ MED EXP (Any one person) $ 5, 000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ EXCLUDED POLICY F7 PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA. ACC $ ANY AUTO $ AUTO ONLY AGG EXCESSIUMBRELLALIABILITY XLS- 0045956 06/05/2008 06/05/2009 EACH OCCURRENCE $ 2,000,000 7 OCCUR 7 CLAIMS MADE AGGREGATE $ B 2000000 $ 2,000,000 $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE WC STATU- OTH- 'f RY IMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS ity of Rexburg, Madison School District & Relay for Life Association is listed as additional insured in regards to the insureds operations. CERTIFICATE Nni nFR CANCRI I ATInN ACORD 25 (2001/08) FAX: (208)359 -3024 © ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Ci ty of Rexb urg BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 12 N. Center OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE G' L Rexburg, ID 83440 Jaime Bradley/3B ACORD 25 (2001/08) FAX: (208)359 -3024 © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) Madison County / City of Rturg GIS ® Page 1 of 1 Z 11111110` DISCLAIMER: This map is intended for display purposes only and is not intended for any legal representations. http: / /gislintranetlarcimsl printable. aspx? MapURL= http:HagentsmithloutputlarelMS _agents... 7/11/2008