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5.j) Fireworks Permit Application08 2015 06:03PM HP Fax page 1 PAID DEC 102015 4100 r; City of Scandia CITY OF SCANDIA Fire Department 15040 Scandia Trail N Date: C.NDIA Scandia, MN 55073 Permit No: Business 651.433.4383 Fax 651.433.5112 cant Marne: z f O lica9l Address: " % y' r.Phone: `/ `7 -- Suite: vy__ State ZIP Cade: tartzed Agent Name: 5 �3 C€ fit Address: Phone: Suite: - -' State Zip Coda: Type and number of fireworks pyrotechnic special effects to be discharged: , Cry-� � -f r: rr► and place storage of t'irewarrks/pyrotechnic special effects to be d`;scharged 7 t Display Location: Date: Tune: Fee: i A. Flat Permit Fee: $100.00 B. State Surcharge: $ ��' Oy rg (.0005 x permit fee) Total A+B $ S IC]CJ • 00 Make check payable to City of Scandia MINNESOTA STATE LAW REQUIRES THAT THIS DISPLAY BE CONDUCTED UNDER DIRECT SUPERVISION OF A PYROTECHNIC OPERATOR CERTIFIED BY THE STATE FIRE MARSHAL Name of Supervising operator;_Yf *a-r-K G / i�s 7 Certification No_: Application Submittal Must Include: 1. Nantes and ages of all assistants that will be participating In the display. 2. Proof of a policy of public general liability bodily injury and property damage insurance, minimum amount of one million dollars ($1,000.000). The City of Scandia shall be named as an additional insured. 3. A diagram of the grounds at which the display will be held. The diagram must shown the point at which the special effects are to be discharged; location of the ground pieces; location of buildings, highways, streets, communication lines and other possible ov obstructions; lines behind which the audience will be restrained. erhead I hereby apply for this permit and I acknowledge that the information above is complete and accurate; that the work wN be done in accordance with the ordinances of the City of Soandia and With the Minnesota State Fire Code; that I will ensure Thai the fireworks,fpyrotechnlos special effects are discharged in a manner that wilt not endanger persons or property; that I understarrt this is not a ,permit but an application for a permit and work is not to start withoul a permit; that the work will be In accordance with the approved plans, speelflcallons and codes. Perlodic andfor a final inspection of thin work Is required by the klinnesota State Fire Code. It is the responsibility Fire Dept al 651.433.4383 to schedule an i a ponsib#Ity of the applicant to cal{ the Scandia pectyon for a ancy andlar use. Applicant or Agent Signature: Date:` — 5 OfficeUse: Required Inspections: pSite Permit Approved 8y: Date, Entered: Issued.- c.09.2015 12:08 PM Chad Stivers 7632677746 PAGE. 1/ 2 CERTIFICATE OF INSURANCE This certificate of Insurance is NOT an insurance pol[cy and does not amend, extend or miter the coverage afforded by the pollcy listed herein. The terms, conditions and exclusions of the policy govern the rights and obllgadons of the Company to the named Insured and any other insureds and may substantially limit coverage. Provisions of any other contract, including agreements between the Insured and anyone else, cannot and do not amend, extend, or aster any terms, conditlons or exclusions In the policy. Additional Insured and other endorsements may be authorized only by the Company or Its appointed General Agent. Where reference is made to an Aggregate Limit, such limit Is the Company's maximum liability under the Policy for the entire policy period regardless of the number of insureds, claimants or occurrences. Date 12/08/2015 NAMED INSURED PC Pvrotac NAMED INSURED'S ADDRESS 4016 Asnan Circle South. Rockford. MN 55373 F INSURANCE COMPANY NAME: National Fire & Marine Insurance Company INSURANCE COMPANY ADDRESS: 3024 Harney Street , Omaha, Nebraska • 68131-3580 POLICY TYPE OF INSURANCE LIMITS INCEPTION NUMBER EXPIRATION 72LPS022982 I COMMERCIAL GENERAL LIABILITY —Occurrence Form ® Premises -Operations ® Products/Completed Operations ❑ Other (Specify) Each Occurrence Limit $ 2.000.000. _ Damage to Premises Rented $ 100,000. Medical Expense Limit (Any One Person) $ 5,000. Personal & Advertising Injury Limit $ 1.000.000, General Aggregate Limit $ 2.000.000_ Products -Completed Operations Aggregate Limit $ rtcluded (Produe(s-Completed Operations are Subject to the General Aggregate Limit) POLICY INCLUDES COMPANY -SPECIFIC NON-STANDARD ENDORSEMENTS WHICH MAY BE RESTRICTIVE OR EXCLUSIONARY IN NATURE. 05/15/2016 05/16/2016 No Certificate is not evidence of additional Insured status for Use cer6fioete holder nor is it descriptive of coverage for any additional insured, The Cortificatshaldar has eon named as an additonal insured under the terms of a M-5350a (05/2009) andomement to the policy. For a description of the coverage, pleaae refer to the polio Show Name: Scandia, Date: 01/30/2016, Rain Date: N/A Location: 15040 Scandia Trail North, Scandia, MN 55073 In the event of any material change In or cancegatlort of said policy, the Oompany's appointed General Agent may, but Is not obligated to, notify the party to whom this Certiflcate Is Issued of such change or cancellation. The COMPANY undertakes no responsiblifty by reason of any (allure to provide such notlficatlon. This Certificate issued to: City of Scandia Y 15040 Scandia Trail North Scandia. MN 55073 M-5238a(0212007) This Certifi sued by: Noidliern Slates Aoencv. Inc. (Comoanv General AaAMI Retail Producing Agent: Innovative Insurance Services 8001 Old Carraige Ct, Suite B Shakopee, MN 55379 NOV/05/2014/WED 05:48 AM PAR Systems FAX No, P,003 In accordance with the prove;oils of TttI U, Qrganued Crime Control Act of 1970, and the regulations issued thereunder (27 CFR Part 555), you may engage in tho activity spec £ed in this license or pormit within the limitations of Cha ter 4 4 � Hired States Code and the regulations issued thereunder, until the expiration date shown. THIS LICENSE S SF rCTl��aiSee "WARNWOS" and "NOTICES° on reverse. Direct ATF Correspondence To Chief. Federal ATF - Chief, FELC 244 Needy Road Martinsburg, WV 254 ss Licensing Center i7E Name GLASOW, MARK Plrembes Address (Changes? Not* 17144 ROCKNEY ST HAM LAKE, MN 55304- Type of License orPermit 50-MANUFACTURER OF QI-A Purchasing Certifi i The licensee or peaminee named above shall 6`ca transferor of explosives to ver* the idewity and o f parmittee as provided by 27 CFR Part 555, e i a simsture. Afaxed. seemed or e-mailed copy launded to be an original signatura is acceptable. Thy Explasves I.ieansee (1=E1.) or a rcapoosi6le person o£t copy of a license or permin issued io the hokiwe arpa business or operaions ql ecZcd above under "Type of Licensee/Permittee Responsible Person Signaturc miIT l"` �1,tr:t:�, �.' .Y: _• y s' h Q{ 0 ds�re •� l IF �jr .. M Ad {SChat. Y sa:tii 71M, r r k ar of the red l� ";�' 17144 � T ) / atrue H 9'3f)A F'o`sitiSn+',.Tifle •`y ' , , FELL of any changes.) Printed Name Date ATE Fam 54W.14/5-".t_ ran I I'MianF-4i«YisObsolete RnisedOctober 20ll Federal Explosives Ucense (F)EL) Custwner Ser%ice Information Federal Explosives Licensing Center (FELC) Toll -free Telephone Number. (877) 283-3352 ATF Homepage: www.atf gov 244Nee4, Road FaxNumber: (304)61(54401 Martinsburg. WV 25405-9431 E-mail: FELC(g?atf gov Change of Address (27 CFR 555.54(a)(1)). Licensees or permittees may during the term of their current license or permil remove their business or operations to a new location at which they intend regularh! to carry on such business or operations, The licensee or perminee is required to give notification of the new location of the business or operations not less than 10 days prior to such removal with the Chic£ Federal Explosives Licensing Center. The license or permit will be valid for the remainder of the term ofthe original license or permit, (The Chieh FELC, shall, if the licensee or perwittee is not qualified, refer the request for amended license or permit to the Director of Industry Operations for dendal in accordance Kith y 555,54.) Right of Succession (27 CFR 555.59). (a) Certain persons other than the licensee or permittee may secure the tight to carry on the seine explosive materials business or operations at the same address shown on, and for the remainder of the tern of a current license or permit. Such persons are: (1) The surviving spouse or child, or executor; administrator, or other legal representative of a deceased licensee or permitteq and (2) A rcceivcr or trustee in bankruptcy, or an assignee for benefit of creditors. (b) in order to secure the right provided by this section, the person or persons continuing the business or operations shall furnish the license or permit for for that business or operations for endorsement of such succession to the Chief, FELC, within 30 days from the date on -which the successor begins to carry on the business or operations. (Continued on reverse side) Cut Here X I— — ---- --———————————--- — — —--- NOV/05/2014/WED 05:48 AM PAR Systems FAX No, P.004 U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Federal Explosives Licensing Center 244 Needy Road Martinsburg, West Virginia 25405 09/30/2014 SUBJECT: Dear MARK 901090: CRR/FLS 5400 File Number: 3MN00 ftz9 3T NE i304-4e29 ms%1erwit: You have been approved as a responsible person under the above -listed Federal explosive license or permit. You may lawfully direct the management or policies of the business or operations as they pertain to explosives. You may also lawfully transport, ship, receive or possess explosive materials incident to your duties as a responsible person. This clearance is only valid under the license or permit referenced above. Sincerely, Chxistop�er R. Peeves Chief, Federal Explosives Licensing Center (FELL) FELC Customer Service, if you believe that information on your "Letter of Clearance" is incorrect, please return a COPY of the letter to the Chief, Federal Explosives Licensing Center (FELC), with a statement showing the nature of the error. The Chief, FELC, shall correct the error, and return an amended letter to you. Mall: ATF Fax: 1-304-616-4401 Cali toll -free: 1-877-283-3352 Chief, FELC Chief, FELC Attn.: LOC Correction Attn.: LOC Correction 244 Needy Road Martinsburg, West Virginia 25405 WWW.ATF.GOV fmOV/05/2014/WED 05:47 AM .rs PAR Systems i i s Ko111'2233a1Og ° f1* -'` &MT—) FAX No, L 1 Oz/L U90 £ o0 :/9 6/80 alva UOi;eaidxEj a;ea 0nij3aJJ3 b0£99 NW '9>1e-1 weH *IS AQUNOo�J VVLL4 MOSe10 I NAVY 9990 :ON 011301;i:Pa0 0:90-L aleow0go 31b�1�112i30 60i'viiDdG Sr�iuiv��iid P. 001