HomeMy WebLinkAboutAPPLICATION - 06-00117 - BYUI - Fireworks6�fts.,
`OPERATIONAL
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LAMI 1UNALFtHMIty-7 APPLICATION PERMIT #:
$50.0-0 FEE PAI YE /NO
Owner. -In formation:
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Owner: IULl/t%C7
Owner Mailing Address:
Property Addres-R: ' � �
PERMIT APPROVED:' E F 0
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Phone Number—
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Business Name Where Work Will Be Done: �-.
Office Address: L ��� y ��r �
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Office Phone Nurrrber: �(_� `���,
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Name.
t Information:
Name of Business: �I T� �'�j2�7'�
Address,, �(% 3�Q
Contact Person: ��''�
ell/Office Number: -
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Contact Person: Contact Phone
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PHONE NUMBER,,-, CELL#
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Parade Route /Assembly Location:
(Map required for Parades} AT &
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TIME:
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SIGNATURE
DATE
Permit #
PLEASE CHE(;KTHE TYPE OF PERMIT(s) YOU ARE APPLYING FOR-
A❑erosol product manufacturing
List of contents:
C Combustible dustmrodupc�ng operations
Location:
Type of dust:
0 Covered mail buildings
Location:
Cry ocien-1c fluids
Types;
� Cutting and welding operations
Location:
❑ Dry Cleaning plants
Location:
Types of Chemicals:
Exhibits and trade shows
Location:
Type of Fire Extinguishers & Location:
❑ Explos Ives
Location:
Types:
IJ Fire hydrants and valves
Locations:
Types.
u Flammable and Combustible liquids
Types:
1 --1
Flour finishing
Types:
F]
L --j Fruit and crop ripening
Locations:
Tues:
� Fumigation and thermal insecticidal
togging
Locations:
Types:
0 Hazardous materials
Locations;
Types:
U, High -piled storage
Location:
Contends:
�
Ho#work operations
Location:
Dates & Timis of Operation.
HPM faci�i # les
Location:
7
Industrial ovens
Location:
Types:
EJ Large capacity battery systems
Location:
Type:
�7
Liquid/gas vehicleslequip, in assembly
buildings
Location:
Type:
LP gas transpo
rtation
Location:
Type.
D Lumber yards/plants
Location:
D Magnesium work
Location:
C Misc. combustible storage
Location:
Type.
Open burning
Location:
Time & Date:
❑ open flames/torches
Location:
Time & Date:
operating amusement bultdings
Location:
2
Additional Information:
IN
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A C�r)Rn ��njir -i
%Jim DATE WM0WnFM
MEW.
PIRCIDUCGR 03/07/2006
t:AV w -
.�,�D$} �,��--��4� THIS CO TIFICATE IS UMUM-AS A MATTER OF IN FORMA17M
fgan, Metcalf & Leavitt ONLY AND CONFERS NORIGHTS "PnM Turwr-pWrImll—il-r-IT
: 2
3780 N. YeIlLOWStone
PO Box -24,98
Zdafm Tail is.ID 834,03
'BREI) -El- e -Pyrotechnics,
2.17 N - 3rd West
Rexburg, ID 8.3440
HOLDER. THIS CERTIFICATE DOES JMOT AMIEt4D$ UT -END OR
ALTER THE COVERAGEAFFORDED SY THE POLICIES BELOW.
WSURERS AFFORDiNG COVERAGE
111C
INSURER A -
INSURER B. -
INSURER C-
'%tmal ffre & Marine
NAIC #
2007,9
INSLIFER E=
TE POLICIES OF INSURANCE .LIED 8EL0
VV HAVE B E EN WSM TO T"E INSURIED NAM ED A-3 FO R T44E 'POSICY PERI 01D WDICATED. NOTWITHSTANDf NG
ANY RMUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR _0T+FR -DM
LIM-ENTVMnlq RESPECT TO WHICH THIS CERWICATE MAY8E ISSUED OR
CON NS 0
_JJAYP_-ERTA[ N, THE INSURANCE AFFORDEL) BY THE . �PWC IES D ESMBED HEWN .1 S SUBJECT TO All THE TERM S, EXC L U S I ONS AND _01TIO F SUCH
CIES_ AGGf?FGATE LJM 11S .SHOWN MAY HAVE BEEN REDUCED S Y SAM CL -Ai MS.
INSR, - DIE
LJR
IN _rYn OF flPL
4StWJNCE -POL-11CY EFFECTNIF -Pik
OXYMMOIBER POLICY EXPIRAT�M
6ENm"LuABfljTyDATCAmmum LIMMS
72LPE-696511: 05/18/206S -05 /1/20�EAcH OCCURRENC
I's -0 00 00
X COMMERCIAL -GENERAL L I L I TY
DAMAGE TO RiATE7_D'
.v 10.0
CLAIMS MADE OCCUR
MM EXP (Any one parson)
A
PEAL & ADVlNJURY 1 000
GENERAL AGGREGATE $
'GEML AGGREGA7E i -I M FT APPL IES PER, 21 0010
PRODUCTS COMR/OP AGS
EXCLUD
POLICY JECT LOC
AUPOSWU UNSLrr-lt
COtvlBINED SINGLE LIMIT
ANY AUTO
ALL OW -4 -H -D ALITOS
]BODILY tNXjFrV
SCHE.DULED AUTOS
Li
HIRED AUll"OS
t- - T, :5.
NON-OWI\EBODILY INJURY
(Per exide-ra)
MA R 2006
PROPEL oAmAGE
-dent)
(Per acc
GARAGE LIABILrTY
AUTO ONLY - EA ACCIDENIF
ANY AUTO
EA'ACC
0774ER T-�"
AUTO ONLY
AGG $
EXCESSAAWRIEll-A Li IL
EACH OCCURRENCE
OCCUR
AGGREGA-ff
DEDUCTIBLE
RE-IFENTI ON $
WORKERS COMPENSATION AND
V11C -S OTH-
r=M-PL0Y'5RS'LlA9fLrTY
Y LL ER
ma
ANY PROPRIET 0RjPAPTNEWyf:Qffj\flE I El. EACH
OFF I CERIMEMBER EX( C -LUDED?
If yes. describe un&r E.L: D ISEA,,--'E - EA EMPLOYE
SPECIAL PROVISIONS Wow
El, DISEASE -'POLICY LfMIT
ti
DESCRIPTION OF OPERA70NS i L'O*CA'nDNS I VEHCLES.jEXCLU9;0NS I'm ORSEWNT t SPECIAL PROVISIONS
E: Insured l�s operations for March 14, A2D OD EOD6E; y E
TIFICATE HOLDER Job- h. i fflft_�j 0 -m
B W- Idaho
525 South Center
Rexbu-rg, ID 83460
ACORD25(2oomm) FAX.. 359-51411
I SHOULD ANY OF 714E-ASOVE DESMSED. PoLICIEs BE CANCELLED BEFORE T! -1E
E3{PIRA7l0N DATE THEFtFOF, TIHE ISSUING INSURER WILL ENDEAVOR TO MAIL
1C) . DAYS WMTRW NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MALZIUCH NOTICE SHALL WOSE NO OBLIGA R LIAWLITY
OF ANY KIND UPON THE INS LJRER, [TS AG514TS OR REPRESENTATWE S.
AUTHORIZED REP. RrzSENTA_RVE
. r - 1. ..
Lynette Fountain/LYFOUN