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300 6TH AVE N (2)0 0 (_0 L) CITY OF EDMONDS FIRE DEPARTMENT PERMIT 07/04/2017 591 123 07/04/2018 Date of Issue UFIR Number Date of Expiration I This PERMIT is issued to: I Greater Edmonds Chamber of Commerce I located at: Edmonds, WA I To engage in the business, occupation or process of: I July 4 th Fireworks Show And shall constitute permission to maintain, store, use or handle materials or to conduct process which produce conditions hazardous to life or property or to install equipment used in connection with such activities as follows: Permit allowing Entertainment Fireworks Inc to engage in a fireworks show described in July forth packet. Entertainment Fireworks is a licensed pyrotechnic company #P- 02820. Insurance and license attached I Allowed Occupant Load: I N Pursuant to the provisions of the International Fire Code, any violation of the Code may be grounds for the revocation of this PERMIT. This permit does not take the place of any license required by law and is not transferable. Any change in the use or occupancy of premises shall require a new permit. Id- I �� 3-� Fire Marshal Fire Prevention Division This Permit Must Be Posted At All Times in The Premises Mentioned Above City of Edmonds Community Development Code 19.25.020 THIS FORM IS INTENDED TO BE USED ASA GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING JURISDICTION AND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON WASHINGTON STATE PUBLIC FIREWORKS DISPLAY PERMIT Applicant Name of Event Greater Edmonds Chamber of Commerce Street Address 300 6th Ave North City Edmonds WA 98020 County Snohomish Event Date July 4, 2017 Event Time Approx. 10: 15 — [:] AM Z PM Applicant's/Sponsor's Name Greater Edmonds Chamber — Phone No. (425) 771-1303 Pyrotechnic Operator Michael E Taylor License No. P-02820 Experienced Assistant's Name Regina Taylor General Display Company Name Entertainment Fireworks, Inc. Phone No. (360) 352-8911 Attach a separate piece of paper and/or copies of the following documents: The number of set pieces, shells (specify single or multiple break), and other items. The manner and place of storage of such fireworks prior to the display. A diagram of the grounds on which the display is to be held showing the point at which the fireworks are to be discharged; the location of all buildings, highways, and other lines of communication; the lines behind which the audience will be restrained; and the location of all nearby trees, telegraph or telephone lines, or other overhead obstruction. Documentary proof of procurement of Surety bond or public liability insurance. Local Fire Code Authority Authority Having Jurisdiction Name of Permitting Official Title Phone No. Permit Granted: F1 Yes E] Yes, with Restrictions (see "Notations" below) E] No Restrictions/Notations Signature of Permitting Official Date of Approval Permit Number If approved, this permit is granted for the date and time noted herein under the authority of the International Fire Code in accordance with Revised Code of Washington 70.77 and all applicable rules and ordinances pertaining to fireworks in this jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is responsible for any and all activities associated with the firing of this show. MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION 30OD-420-050 (R W13) Pleasejnail,permit to tain% Entertainment Fireworks, Inc. Post Office Box 7160 IF Olympia, WA 98507-7160 Ng (360) 352-8911 Fax: (360) 352-0205 11 EVENT DATE: July 4, 2017 License Number: C-04085 SPONSOR/NAME OF EVENT: Greater Edmonds Chamber of Commerce LOCATION OF DISPLAY: 300 6th Ave North, Edmonds WA 98020 MANNER & PLACE OF STORAGE PRIOR TO DISPLAY (Subject to approval of Local Fire Authority) Delivered to site day of display. ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. Type of Fireworks 2.5" Salutes 2.0" Aerial Shells 2.5" Aerial Shells 3.0" Aerial Shells 3.0" Mines .8" - 1.5" Multi -shot Cake Devices Set Piece(s) of Lance Work Type of Fireworks SIGNATURE OF APPLICANT: TerriSchuette, I W"I EdmOnqsj?ojic'e - %A 'U dmonds". )af Court-,,, Az� e C6rpus Mm Al L S I OEM,, pfwmp� A�' "-0 a Was'a 5 urch -T ROOM MA 5-0-64 ,4400RDO CERTIFICATE OF LIABILITY INSURANCE OA-W(MM=r'y" 1 4/6/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMA71VELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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 andorsament(s). PRODUCER Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CONTACT Kristen Look NAME: FAX = r-rt)- 425-586-1016 (ALG. No,, 425-451-3716 E-MAIL INSURER(S) AFFORDING COVERAGE NAIC 0 INSURERAJ.H.E. Insurance Company 12866 INSURED ENTEFIR-01 INSURER B: INSURERC: Entertainment Fireworks, Inc. 13313 Reeder Rd. SW ENTEFIR-01 INSURER D: 11 Tenino WA 98589 INSURERE: INSURER F: QnVr-RAQr-S C17-14TIFICATF NUMRFR. 632709632 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYP E OF INSURANCE ADDI-SUOR INSD WVD POLICY NUMBER POLICY EFF (MMIDDNYYY) POLICY EXP 1MMIDDNYYYI LIMITS • X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 51OCCUR CPP0103972-03 2/15/2017 2/1512018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Es occurrence) $100,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 L AGGREGATE LIMIT APPLIES PER: PRO - POLICY D JECT 7 LOC M'OTHER: GENERAL AGGREGATE $ - COMP/OP AGG $2,000,000 -PRODUCTS $ • AUTOMOBILE LIABILITY ANY AUTO ALL OWNED EX SCHEDULED AUTOS AUTOS UTOS X NON -OWNED X HIRED A AUTOS CPP0103972-03 2/15/2017 2115/2018 COM13INED SINGIE 101r_ (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ _VR_0TE_RT_YD_AMAGE (Per accident) $ UMBRELLA UAB EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ HOCCUR AGGREGATE $ Fi DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? El (Mandatory In NH) IfrsWescibe under D RIPTION OF OPEELTIONS below NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ T_ DESCRIPT10N OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, AddtUonai Remarks Schedule, may be attached If mom space Is required) Certificate holder is included as an additional insured on the General Liability policy perform number CG1 33F (07/95). Date of Display: July 4, 2017. Location: Civic Playfield @ Edmonds WA. Addl. Insured: The Greater Edmonds Chamber of Commerce; City of Edmonds; Edmonds Fire Dept.; their officers, agents, and employees when acting in their official capacity as such. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Greater Edmonds Chamber of Commerce THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 146 ACCORDANCE WITH THE POLICY PROVISIONS. Edmonds WA 98020 USA AUTHORIZED REPRESENTATIVE I I . t�p' 't I 9) 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED - FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional insured: 1 . The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on behalf of the Named Insured; but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. All other terms and conditions of the policy remain unchanged. CG133F(07/95) THIS FORM IS INTENDED TO BE USED ASA GENERIC PUBLIC DISPLAY PERMIT FOR THE AUTHORITY HAVING ., JURISDICTIONAND PYROTECHNIC OPERATORS WITHIN THE STATE OF WASHINGTON WASHINGTON STATE PUBLIC FIREWORKS DISPLAY PERMIT Applicant Name of Event Greater Edmonds Chamber of Commerce Street Address 300 6th Ave North City Edmonds WA 98020 County Snohomish Event Date July 4, 2016 Event Time Approx. 10:15 — F1 AM 0 PM Applicant's/Sponsor's Name Greater Edmonds Chamber Phone No. (425) 771-1303 Pyrotechnic Operator Michael E T Experienced Assistant's Name Regina Taylor License No. P-02820 General Display Company Name Entertainment Fireworks, Inc. Phone No. (360) 352-8911 Attach a separate piece of paper and/or copies of the following documents: The number of set pieces, shells (specify single or multiple break), and other items. The manner and place of storage of such fireworks prior to the display. A diagram of the grounds on which the display is to be held showing the point at which the fireworks are to be discharged; the location of all buildings, highways, and other lines of communication; the lines behind which the audience will be restrained; and the location of all nearby trees, telegraph or telephone lines, or other overhead obstruction. Documentary proof of procurement of Surety bond or public liability insurance. Local Fire Code Authority Authority Having Jurisdiction Name of Permitting Official o' Title R\(Zl Phone No. 4 a, 1.3 Permit Granted: lwyes X�es, with Restrictions (see "Notations" below) No . alll( 3-��r IIA4_e�� 6 _�Oy —14P Sighature of PkT!0g Official Date of Approval 4'A Permit Number If approved, this permit is granted for the date and time noted herein under the authority of the International Fire Code in accordance with Revised Code of Washington 70.77 and all applicable rules and ordinances pertaining to fireworks in this jurisdiction. This permit is INVALID unless in the possession of a properly licensed Pyrotechnic Operator, who is responsible for any and all activities associated with the firing of this show. MUST BE APPROVED BY THE AUTHORITY HAVING JURISDICTION 3GOG-420-050 (R 3/13) Plea$ mail permit to Entertainment Fireworks, Inc. Post Office Box 7160 F Olympia, WA 98507-7160 (360) 352-8911 Fax: (360) 352-0205 %brksl% EVENT DATE: July 4, 2016 License Number: C-04085 SPONSOR/NAME OF EVENT: Greater Edmonds Chamber of Commerce LOCATION OF DISPLAY: 300 6th Ave North, Edmonds WA 98020 MANNER & PLACE OF STORAGE PRIOR TO DISPLAY (Subject to approval of Local Fire Authority) Delivered to site day of display. I ONLY THE BELOW LISTED PRODUCT DESCRIPTION ARE AUTHORIZED FOR THIS DISPLAY. I Type of Fireworks 2.5" Salutes 2.0" Aerial Shells 2.5" Aerial Shells 3.0" Aerial Shells 3.0" Mines .8" - 1.5" Multi -shot Cake Devices Set Piece(s) of Lance Work Type of Fireworks SIGNATURE OF APPLICANT: Terri Schuette M FS1110 I a .:-;i, gm, 42101, -t7,- zz kMM Zk Mot,, �� Map klFR— HV -4 S t 2 Oqq, — �Z, �gp j 0 ME Q�ft Z" M "I'MI$ d i j R bk ;--T A 51 V 2* t 5 ­� . ...... '001 '94ge �Y-A. ;l k-1 30 7 V, kv lun� U lip CAR WAIN"; �4-- AZT Ok R, "tki Jl: C� 4P IMAVA �, # RN I'M 4 ! 0A t lK 4.1 41 -zW I n, YWI 'i , 'V, 3W W ti t ,T, T� L ?,LLO g; ,P 01 W ii4 t 4�1004- ACOORLO CERTIFICATE OF LIABILITY INSURANCE DATE (MWDWYYM 1 4/512016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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). PRODUCER Arthur J. Gallagher Risk Management Services, Inc. 777 108th Ave NE, #200 Bellevue WA 98004 CON Kristen Look -NAME: I FbX = E14, 425-586-1016 Nall 425-451-3716 E-MAIL INSURER(S) AFFORDING COVERAGE NAIC # INSURERA-T.H.E. Insurance Company 12866 INSURED ENTEFIR-01 INSURERB: INSURER C: Entertainment Fireworks, Inc. 13313 Reeder Rd. SW ENTEFIR-01 INSURER D: Tenino WA 98589 INSURER E: INSURERF: ('=0Tl=l('AT1= FJHMRF92- 17268P5231 REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLIbUISK INSID WVD NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) LIMITS • X COMMERCIAL GENERAL LIABILITY _-POLICY CPP0103972-02 2115/2016 2/15/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE 7x OCCUR _7 DAMAGE ERENTED PREMISESO( a occurrence) $10 0,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRODUCTS -COMP/OPAGG s2,000,000 POLICYF—] PRO- 7 LOC JECT M'OTHER: $ I I • AUTOMOBILE LIABILITY CPP0103972-02 2/15/2016 2115/2017 COMBINED SINGLE LIMIT accident) $1,000,000 _(Ea BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED S HED LED AUTOS F -7 ASTOS U NON -OWNED X HIREDAUTOS AUTOS PROP�ER ' ZtDAMAGE (Per a d $ UMBRELLA LIAB EACH OCCURRENCE $ HOCCUR AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE I I I STE RT OTH- A UTE ER E.L. EACH ACCIDENT , $ E.L. DISEASE - EA EMPLOYEE $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) NIA E.L. DISEASE - POLICY LIMIT 1 $ If ies S6 describe under D RIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached R more space Is required) Certificate holder is included as an additional insured on the General Liability policy per form number CG133F (07/95). Date of Display: July 4, 2016. Location: Civic Playfield @ Edmonds WA. Add[. Insured: The Greater Edmonds Chamber of Commerce; City of Edmonds; Edmonds Fire Dept.; their officers, agents, and employees when acting in their officiall capacity as such. The Greater Edmonds Chamber of Commerce PO Box 146 Edmonds WA 98020 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VVILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA77VE (0 1955-ZU14 At;UKU 4.;UIKI-VMA I IVN. Kli rignis reberveu. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED - FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional insured: 1 . The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on behalf of the Named Insured; but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. All other terms and conditions of the policy remain unchanged. CG133F(07/95) Name Location License Number Work Phone Expiration Date Julienne Marie Weiner Portland, OR 97202 P-04291 (503) 317-4768 January 31, 2017 ------------------------------------ Scott Westering Puyallup, WA 98371 P-02711 (253) 535-8311 January 31, 2017 ------------------------------------ Nmwmffm�� Renton, WA 98056 P-04092 (425) 652-3384 January 31, 2017 ------------------------------------ William Chadwick Glenoma, WA 98366 P-04432 January 31, 2017 Whitnell Bruce D. Wiedemann Vancouver, WA 98661 P-04356 (000).000-0000 January 31, 2017 ------------------------------------ Chad Williams Vancouver, WA 98682 P-04424 (503) 8,80-1032 January 31, 2017 ------------------------------------ Christopher A Silverdale, WA 98383 P-04036 (360) 476-3709 January 31, 2017 Williams Gary D. Wilson North Bend, WA 98045 P-02767 (425) 888-6344 January 31, 2017 ------------------------------------ Fred Wiltse Brewster, WA 98812 P-04416 (509) 689-4041 January 31, 2017 ------------------------------------ David B. Wingo, Jr. — — — — - — — — Endicot� WA 99125 — — — — --- ---- P-04103 (509) 648-8200 — — - — — — January 31, 2017 — — — — Jay Woodward Snohomish, WA 98290 P-02899 (360) 805-1538 January 31, 2017 ------------------------------------ Michelle Wuscher Gig Harbor, WA 98335 P-04359 (360) 791-0745 January 31, 2017 ------------------------------------ John Yagi Snohomish, WA 98296 P-02958 (000) 000-0000 January 31, 2017 ------------------------------------ Bellingham, WA 98226 P-04363 (360) 319-8347 January 31, 2017 ------------------------------------ Peter L. Zink Lynnwood, WA 98037 P-04315 (206) 949-2674 January 31, 2017 ------------------------------------ ------------------------------------ Ferndale, WA 98248 P-04361 (360) 510-9018 January 31, 2017 The information provided in this document is made available by the Fire Protection Bureau to assist fire authorities, goverment agencies, the general public, and regulated entities in identifying licensed Pyrotechnic Operators and to assist all in complying with the fireworks laws and regulations. "Commercial purpose" means using or intending to use information for the pur ,pose of facilitating a profit -expecting business activity. Monday, May 2,2016 Please see disclaimer on page 12 Page 12 of 12 Name Location License Number Work Phone Expiration Date Eric M. Storm Eatonville, WA 98328 P-04222 (206) 437-8693 January 31, 2017 ------------------------------------ Jeffrey Story Wenatchee, WA 98801 P-04399 (509) 415-0139 January 31, 2017 ------------------------------------ Scott Streeper Tacoma, WA 98405 P-04159 (206) 930-6969 January 31, 2017 ------------------------------------ Edward D. Stutzman Otis Orchards, WA 99027 P-04341 (000) 000-0000 January 31, 2017 ---------- / -------------------------- WAMArmulewra Monroe, WA 98272 P-02820 (360) 794-2299 January 31, 2017 ------------------------------------ YRUP" 800� Monroe, WA 98272 P-02821 (000) 000-0000 January 31, 2017 ------------------------------------ Nick P. Trehuba Tenino, WA 985898602 P-04431 (206) 459-0917 January 31, 2017 ------------------------------------ Wayne A. Ulrich Rathdrum, ID 83858 P-02850 (509) 370-6209 January 31, 2017 ------------------------------------ Steven R. Underwood Newman Lake, WA 99025 P-04125 (000) 000-0000 January 31, 2017 ------------------------------------ Joshua D. Vaughan ------------------------------------ Spokane Valley, WA 99206 P-04272 (509) 467-9282 January 31, 2017 Richard R. Vaughan Spokane, WA 99218 P-02957 (509) 467-9282 January 31, 2017 ------------------------------------ Jason A. Veentjer Marysville, WA 98270 P-04344 (000) 000-0000 January 31, 2017 ------------------------------------ Janice Ventura Seabeck, WA 98380 P-04334 (360) 830-0114 January 31, 2017 ------------------------------------ Daniel VerHeul Spokane, WA 99206 P-04083 (000) 000-0000 January 31, 2017 ------------------------------------ Jameson Voie f Winlock, WA 98596 P-04328 (360) 508-0449 January 31, 2017 ------------------------------------ Daniel Walsh Seattle, WA 98177 P-04152 (000) 000-0000 January 31, 2017 ------------------------------------ Thayne Wastman Edmonds, WA 98026 P-03029 (425) 355-2826 January 31, 2017 ------------------------------------ Aaron Webb Olympia, WA 98502 P-04311 (360) 790-3409 January 31, 2017 - ------------------------------------ Herb Weiner Portland, OR 97202 P-04289 (503) 771-1400 January 31, 2017 Monday, May 2,2016 Please see disclaimer on page 12 Page 11 of 12 4 FIRE PREVENTION Sdwq,ing,Brr0-,,Edthonds, and 1242 MeridianAve S INSPECTION REPORT"! NOHOMISH CO. c -EfEDMONDS Mountlake Terrace Ei)�i-ett, WA 98208 0 BRIER RE Phone (425) 551-1200 0 MOUNTLAKE TERRACE DIS 0 UNINCORPORATED WHIIVFireDistrictl. org Fax (425) 551-1272 FREQUENCY STATION& SHIFT LOCATION: 3M 6,.th Ammiue N MUD Antu 17-0 DUOINESS NAME: C.ML CznLcr Ckw&land PHONE: SCHEDULED�pr 2014 DATE DUE MAILING UFIR 0123203 ADDRESS: 300 fiUl Avon= N. I;d VA 08M BUSINESS OWNER: HOME PHONE: EMERGENCY-1: C4 01 LdrMr(& HOME PHONE: 42G7r525z CURRENT KEY ACCESS-2: HOME PHONE: CITY YES NO EMAIL: BUSINESS -1 F El LICENSE PERSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR: FEll)-iL7 HAZARDS FOUND AND LOCATIONS COMMUNICATIONS 7f� 'r, OA-zo—s— t2 2 3 3 4 4 5 5 zz 6 6 7 7 Tst RE -INSPECTION 2nd RE -INSPECTION i , , EXTENSION ll�_IRAITIITO: FINAL RE -INSPECTION DLAJIONS DATE,PAW., .2 E DPE�4.,, DATE DUE: CITED. PERSON I PEA96NIF PYNTACTED: CONTACTED: PERSON CONTACTED: INSPECTOR: INSPECTOR: INSPECTOR: 2 DATE: DATE: DATE: 3 VIOLATIONS VIOLATIONS PRE -CITATION CITATION ISSUED 1 5 1 5 LETTER SENT NUMBER: 4 2 6 2 6 DATE: CODE SECTION: 5 RETURN RECEIPT 6 3 7 3 7 RECEIVED DISPOSITION: 4 8 4 8 DATE: 7 LETTERNEEDED F] YES NO LETTER NEEDED E] YES El NO �lv 8 FIRE DEPARTMENT COPY Serving Brier, Edmonds SliOHOMISH CO. F I R Mbuntlak� Terraceand DISTR, the Town of Woodway T www.Firei)istrictl.org LOCATION:— 300 6th Avenue BUSINESS NAME: Civic Center Grandstand MAILING 300 6th Ave N ADDRESS: Edmonds BUSINESS OWNER: City Of Edmonds I Z FIRE PREVENTION 12425 Meridian . Ave S INSPECTION REPORT 0 EDMONDS Everett, WA 98208 OBRIER OWOODWAY Phone (425) 551'1200 - 0 M 0 U N T 11K E T E k fi'A4"i C� Fax (425) 551-1272 0 UNINCO0ORAfIEDl_'. PHONE: 98020 HOMEPHONE: 4257752525 FREQUENCY STATION & SHIFT 366 17 C SCHEDULED DATE DUE 0 04/01/13 UFIR 0 123 4203 ACTIVE 993 EMERGENCY-1: HOME PHONE: CURRENT KEY ACCESS-2: Yakinhoff, Ivan HOME PHONE: 4258721991 CITY YES NO BUSINESS LICENSE El El RSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR: FIRE FE I SYSTEMS: ANNUAL11 HAZARDS FOUND AND LOCATIONS COMMUNICATIONS 6,, J (q 2 2 3 3 4 4 5 5 6 6 .7- 7 I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 D.AYS X lst RE -INSPECTION 2nd RE -INSPECTION FINAL RE -INSPECTION EXTENSION VIOLATIONS DATE DUE: DATE DUE: GRANTED TO: DATE DUE: CITED: PERSON PERSON PERSON CONTACTED: CONTACTED: CONTACTED: I INSPECTOR: INSPECTOR: INSPECTOR: 2 DATE: DATE: DATE: 3 VIOLATIONS VIOLATIONS PRE -CITATION CITATION ISSUED 1 5 5 LETTER SENT NUMBER: 4 CODE 5 2 6 2 6 DATE: SECTION: RETURN RECEIPT 3 7 3 7 RECEIVED 6 DISPOSITION: 4 4 8 DATE' LETTER NEEDED YES NO I LETTER NEEDED C] YES I—] NO r \. 8 FIRE DEPARTMENT COPY CITY OF EDMONDS 121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215 FIRE DEPARTMENT t Is LOCATION: 300 6th Avenue N BUSINESS NAME: Civic Center Grandstand PHONE: MAILING 300 6th Ave N ADDRESS: Edmonds 98020 BUSINESS OWNER: City Of Edmonds HOMEPHONE: 4257752525 EMERGENCY-1: HOME PHONE: KEY ACCESS-2: Yakinho'g, Ivan HOMEPHONE: 4258721991 FIRE PREVENTION SAFETY SURVEY FREOUENCY STATION & SHIFT' 366 17 D SCHEDULED DATE DUE 0- UFIR 11 123 4203 ACTIVE 993 PERSON CONTACT - ED: INITIAL INSPECTION - DATE NAME OF INSPECTOR: AlA 5, *7- 7 - lo FIRE FE SYSTEMS: ANNUAL HAZARDS FOUND AND LOCATIONS COMMUNICATIONS M0 V, 0 10 -.7 �0 C4 4 ENTER CODE ONLY ONCff 10 VIOLATION CODE 2 2 3 3 4 4 5 5 6 6 7 7 8 8 1st RE -INSPECTION DATE DUE: 2nd RE -INSPECTION DATE DUE: 1 EXTENSION GRANTED TO: FINAL RE -INSPECTION DATE DUE: VIOLATIONS CITED: PERSON CONTACTED: PERSON CONTACTED: PERSON CONTACTED: INSPECTOR: INSPECTOR: INSPECTOR: 2, DATE. DATE. DATE. 3 VIOLATIONS 1 5 VIOLATIONS 1 5 PRE -CITATION LETTER SENT CITATION ISSUED NUMBER: 4 2 6 2 6 DATE: CODE SECTION: 5 3 7 3 7 RETURN RECEIPT RECEIVED 6 7 4 18 4 8 DATE: DISPOSITION: � LETTER NEEDED [] YES C] NO LETTER NEEDED F] YES NO FIRE DEPARTMENT COPY