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HomeMy WebLinkAbout15-16422 � , CITY OF ZEPHYRHILLS � 5335-8TH STREET � ' (8�13)780-0020 �`4LL FIRE WORKS PERMIT PERMIT INFORMATION LOCATION INFORMATION Permit Number: 16422 Address: 4241 SKYDIVE LN Permit Type: FIRE WORKS ZEPHYRHILLS, FL. Class of Work: FIRE WORKS Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 18-26-22-0010-08600-0000 Improv. Cost: OWNER INFORMATION Date Issued: 7/01/2015 Name: CITY OF ZEPHYHRILLS Total Fees: 530.00 Address: 4241 SKYDIVE LANE Amount Paid: 530.00 ZEPHYRHILLS, FL. 33542 Date Paid: 7/01/2015 Phone: Work Desc: SPECIAL FIREWORK EVENT- JULY 4, 2015 9PM- MIDNIGHT CONTRACTOR S APPLICATION FEES HAYES,JOHN DAVID FIRE PERMIT FEES 500.00 CONTRACTOR ERTIFICATE 30.00 i� (� r � � � - i � Ins e ' ns Re uired FIRE WORKS SITE INSP CTION Chapter 633, Florida Statutes,authorizes the Ci to charge and collect user fees to pay for the costs of fire prevention and protection related activities such as inspections, plan review,administrative fees,and other costs relate to the aforementioned. Complete Plans, Specifications and Fee Must Accompan Application. Commencement of work without written approval of the Fire Department's Fire Marshal or required permi or opening up for commercial activity without an approved final inspection shall be charged double permit fee per da of operation or a minimum of$100.00, whichever is greater. All work shall be performed in a �cordance with City Codes and Ordinances. "FIREWORKS" per Section 791.01, Florida S tutes are considered as any combustible or explosive composition or substance or combination of substances or,except as hereinafter provided,any article prepared for the purpose of producing visible o�audible effect by combustion,explosion,deflagration,or detonation. 1--- CONTRACTOR IGNATURE PERMIT OFFIC ' PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION ' CALL FOR INSPECTION - 8 HOURS NOTICE REQUIRED ZEPHYRHILLS FIR� RESCUE DEPT- 813-780-0041 T ' � _._ � .�� � { � �:,::,DRIVER IICENSE C�E '�� � -�!�H2O0=4g4-61-005-0 1` � ' ; JONN DqVID � I � , HAYES � 3137 Wql,��DR ZEPHRYhl1L`-L.5 F�3�r�1.472.t ;DOB:01-05-'!9¢.1 SEx:M. , '200d HG'i.6-02 ;. j , . f'-261'7� �, - ' �_����i'= --- -__ � , ��"'" � � . � f•�,� � , �++oR- +�..�.=io,s ' - OGerotioaota� SAFE'pjuyER ,- - � _ -'�' motor vthicle Fonstiw:rs cotna_' ' �, -'° --._._'�„____`.__ m ta�ny.soGriery hst reduib M law. " --_-�._-�_�_--____., � SS�V �'9 �� � . _ � � ��/ � 0 , � ; � � Tempor.ary `Sales �C�hecklist �(( (� City Qf Zephyrhills V' ' ` �" l �Z� 5335 8`�Street Zephy�hills,�Fl.33542 Phone:813-780�0020/Faz:813-780-0021 REQUIREMENTS Detailed Plot Plan showing setup of loca ion. Refer to Ord 1038-09; Sec 5 Notarized letter from property owner sta ing their approval. A flame retardant certificate is required IF a tent is involved.Inspection required once tent is erected and prior to opening for business. Approved certified fire extinguishers p I NFPA 10. ` No Smoking signs must be placed outsi e entrances. IF there is a wire fence or chain link f cing must have at least 5 Ft setback from tent and at least 2 exits. IF tent has sides,the sides shall be in the up position unless there is inclement weather, then 2 sides must be in the up position. FIREWO .REQUIREMENTS—(In addition to the above) � Proof of State License. r Proof of Liability insurance. �List of items to be sold at site. l' Copy of Drivers License and Social Security Number of all personnel dealing with the sale of fireworks at the tent location. FEEs � • - . $30.00—City Registration(If egulated by DBPR—Fee is Waived) � $500.00—Fireworks fee-Fire�epartment fee - $ 5.00—Temporary Sales Fee for lst two days $ 1.00=Temporary Sales Fee per day for each consecutive day thereafter,not to _ exceed duration of 7 onsecutive days and no more than two occurrences during a 12 month�eriod on same property Ord#1038-09,Sec 6 $50.00—Tent Fee(40.00BD, 15.00*/FD)—(*$15.00 waived for Fireworks) $40.00—Electrical Fee(if applicable) Property Owner: � � � � C�� �-�P�l�fT l L�� � ���U� �-l �� , Applicant: � 'd ���1 � `�� � � /� � Phone Contact: � � ?J � � q �` b� � � � . Address Site: � Z L� � ��� �� � � L� Z�l C�-� � �S �{� Date(s)of� � 1 S�L I� I �J LY � - �,v� --? f►'� t��J1 Gff % Ordinance No. 1038-09(for additional requir � ents) , � . �' AIRPORT' LIABILITY POLICY DECLARATIONS -PART ONE Company: U.S. SPECIALTY INSURANCE COMPANY UA00167344-05 Your Policy Number: • Administrative offices: 13403 Northwest Freeway, prior Policy Number: UA00167344-04 • Houston, TX 77040 ITEM NAMED INSURED AND ADDRESS YOUR AGENT'S NAME AND ADDRESS Individual � Skydive City, Inc. Falcon Insurance Agency, Inc. � P. O. Box 291388 Q Partnership Kerrville,TX 78029 or Joint 4241 Sky Dive Lane Venture Zephyrhills, FL 33542 � Other 2 POLICY PERIOD: 12:01 a.m. standard time at o�1r above address FROM: 02/18/2015 TO: 02/18/2016 3' BUSINESS OF NAMED INSURED: I 4 PART OCCUPIED BY NAMED INSURED'S LOCATION OF AIRPORT INSURED BY THIS PC�LICY NAMED INSURED INTEREST ZEPHYRHILLS MUNI, ZEPHYRHILLS, FL Portion Tenant 5 LIMITS OF INSURANCE, COVERAGES AND PREMI MS:This insurance is only with respect to the following coverage(s) ' for which a premium charge is shown in the premium c�lumn.Absence of a premium charge means that no insurance is i provided by the policy for that coverage. , LIMITS OF INSURANCE COVERAGES PREMIUM $ 100,000 Each Person AIRPO T $ 1,000,000 Each Occurrence A BODIL�' INJURY AND PROPERTY DAMAGE LIABILITY $ 1,500 $ 2,000,000 A re ate $ Any One Aircraft $ Each Occurrence C HANG I RKEEPER'S LIABILITY $ Deductible 4 COVERAGES APPLICABLE TO ALL AIRPORT( ) 1NSURED BY THIS POLICY LIMITS OF INSURANCE, COVERAGES AND PREMII�MS:This insurance is only with respect to the following coverage(s) 5 for which a premium charge is shown in the premium cl lumn.Absence of a premium charge means that no insurance is rovided b the olic for that covera e. LIMITS OF INSURANCE I COVERAGES - PREMIUM $ Each Person PROD�CTS COMPLETED OPERATIONS HAZARD $ Each Occurrence B BODIL INJURY AND PROPERTY DAMAGE LIABILITY $ A re ate $ Each Person p MEDI�AL PAYMENTS $ $ Each Occurrence 6 Premium for Endorsement s 0 Forms and Endorsements attached: TOTAL POLICY PREMIUM 1,500 Form Name Form Version Form Title Form Premium 20210 (08/10) FLORIDA CHANGES-C NCELLATION AND NONRENEWAL 20702 (04/11) ASBESTOS EXCLUSIOI� 20001 (08/10) AIRPORT POLICY CONQITIONS 20003 (08/10) AIRPORT LIABILITY PO I ICY JACKET 20002 (08/10) Document Nurnber: 575269 Page 1 of 2 � . i 2 ' AIRPORT IABILITY POLICY DECLARA IONS - PART ONE Company: U.S. SPECIALTY INSURANCE COMPANY Your Policy Number: UA00167344-05 • Administrative offices: 13403 Northwest Freeway, Prior Policy Number: UA00167344-04 • Houston,TX 77040 � 20080 (OS/10) PROTECTING THE PRIVA Y OF INFORMATION 20030 (08/10) EXTENSION-AIRPORT 0 ERATIONS ADDITIONAL INSURED 20031 (08/10) EXTENSION-LANDLORD ADDITIONAL INSURED � 20053 (08/10) EXTENSION-PARACHUTI G ACTIVITIES,LIMITED � PRODUCTS-COMPLETED OPERATIONS I PREMIUM RATE Covera e A licable Onl With Res ect To The Fbllowin Classification BASIS er$1,000 Flat Charge Minimum Premium $ Countersigned: Authorized Representative 20002 (08/10) Document Nurrlber: 575269 Page 2 of 2 � r ' � � THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. : This endorsement is issued by U.S. Specialty Insurance Company Policy number : UA00167344-05 Endorsement number . , Issued to (first Named Insured) : Skydive City,Inc, Effective : 02/18/2015 For : premium of$ (The above information is required only when this endorsement is issued subsequent to preparation of the policy.) EXTENSION - AIRPORT OPERATIONS ADDITIONAL INSURED SCHEDULE Name of Person or Organization: Pasco County 8731 Citizens Dr., New Port Richey, FL 34654 a WHO IS AN INSURED (Section II) of this policy is ' amended to include as an insured the person or organi- zation shown in the Schedule but only with respect to liability arising out of your ownership, maintenance or use of the covered premises. In addition to the other exclusions of this policy, this insur- ance does not apply to liability for which any person or organization shown in the Schedule may be held liable by reason of: 1. Manufacturing, selling, handling, distributing or dis- posing of any goods or products, or 2. Any work or operations performed by or on behalf of the person or organization shown in the Schedule, including materials, parts or equipment furnished in connection with such work or operations. 20030 (08/10) Page 1 of 1 r'edera! LzplosiYes License/Fermit U.S.Departme Justice Bure�u of A1c� obacco,Firearms and Explosives �-r$ U►S� e�lap��1'4Q� ������� � Tn accordance with the provisions of Title XI,Orgazuzed Grime Control Act c�f 1474,and the regulations issued thereunder(27 GFR.Part 555),you may engage in the activity specified in this license or permit within the limitations of Chapt 40,Tit�e_18 U'nited States Code and the regulatians issued thereunder,until the ,� , ,:. .:�-��..,,- ' tion dste shown. THIS LICENSE IS NOT TRANSFERAB�,E I71�f ER=27.CER 555:53._See"WARNINGS"and'N0ITCES"on reverse. i °ATF ATF-Chief,FELC `;'� �.;r;�;=�_��� �5;�,,��icensel�:ermrt�-• Corres ndence To 244 N Road �'"'" � ��Y I�ucn'ber � ° - � • � �}' � c.'>rf+:,-�` •�.�-> r�r ��. ,�, .. � • i i • • • Martinsburg,W V 254Q5-9431` `�'"`�., .'W�.'''� �'"' ��.'' `"k � Y`'�"�" ` _. _ _.���.�;:�.1��,,��.. ��. .. ��..{:s,u..�.:-�>a�°>.;-� r S , aa,.�.�'h f:.'4 f1�n,'3�s .. »._ _ •-•. x^r .__�r.��.<.a�,.m K.�,`.. Chief,FederatE losivesLicensingCenter(FEL � �'� ��1,� �<<,a-�'-s`%"�"�'" Expiiafson���,sr�"a f � x f�..F. 1 • i"x�G�1/.i�[ �'` � '`.`-.:, ;,`�.w;;��'y ���'"r� Date ��°.:�# 3''� `�f�'� �` ` '.v':.'r." ~*�is:kp '!°f' "�':�E2Y"...'EY:1.'.�M:-...,,_• �..�. �.�„'•T�� ' _ .Y�.,°3��r,.� Name .w �>Y,�� >r , , . . , ;;t�;;?`�'=•„-�` ;"� : " �,;r.;`�;., j� ,,.., . HRYES,JOHN DAVID =:4=�`' �;:r' pa{� --`'��_� ',�.' =`''°_'� ,r Fi.r`xr'�'� '-�'�.�.�y:.,. '.;i= ,yt:a";` • _✓s�f r,t2CU aY;:N�:`f�":W�- '��::'•:4�.'' - - - - .:?%`z ' }t i . '�..''::r_','=" .,.'}��-z - - { � .r:r.:f•�� _.l.N•,An•.2:�� ���f ' �Ci., Premises Address(Changes?NoUfythe.FET���least}10 days�beforethe�.muve�h�.���, �r �' , y�4 rM °� �'_� � ; 3137 DIANA DRIVE h�; �t ' � , .�€f.4� �jg .r� } �E�.�„4 "`t`I-+«.r� a �; p� r u r ''>: ZEPHYRHIL.LS FL83541= :��; �`;�� �.��3. .,r�;'���;fl:%r� 'h�:�;��:� ,% _ ?� :.e;�;;.s� ����. �.:� �:;,. Type of License or Ferniit '��Y};�;�� �;r'c��.„` �<����°-` � r:,'" ;�?`s.; ;s�>' �' - y{��, :`�;�z�; :� r::;;,^.� h �{ .'v'4. •sa�.�'�"'rr�'ii':- � .F,:S��.:y�". _ �' t�:f, �!x��.,Y4��;� �I.'y,.^aiir�� j'' » '�~�' ..'.' .�'� 54-USER OF EXPLOSlVES�' ". •::�X"`� >:µ"'�::� - "'=__;< ,'�";��'�� , '':n;,n ' ' �..: ''l..�� ''�5:�, 'C3;>„F.nt"` " �3;"if+'3 r " 01.!.-'-�..V'.Y S'�.�...'.,...,..i✓,': �s, Puzchasin CettifccatioritlSEatenigiit; ,� ,�- ,3, - :i,'�� µ",r g G. °c�f'�;� •;; x Mailing'Adiliess;{Chari es?�qNotify the FEI,C of any changes.) ��Y .,�,.,�•, s ,... , -_ r., .,�, �;j_•,_ �,�� , The lic�see or p�niltee named above shall use a"cqPj'.,offltislioense�o�p�to�ass .a�:.:,-;T„r. - r,.ti w st:;�;�: ,� �,y.<;f':" . ;- � 7c. .. 1�_�r�..:. .F�'".;.��:. - _ .'e':,-.. traus�ervrofey�losivestov(+���{j theidem andthe.Ticensedstati�safth�liceiisee;or;.' _ �'::�''y:�`,.� "7' "�'�J � . .,a., . � �`>}, M''i��e�.���yi°.:'.."r+'+' -.v$`�°....'�::'Fr� _ pecmitieeasprovidedby27C Pari555. �""`� X � - �"� `.,.:_ -v`',�`�`:��,_ ":"��``~ ��:'�` , `��''� -'' � FR The si�nalure:�,e.ach�ov mnsi`.3ie�aii- einai`'�� >: t»�-HAYES JQH�N��[7AV�D simature. Afaxed,scanned or e-mailed copy ofthe�license of'p�erituE;with a sign"aWre '"``".'-a':�:�;: ' ..-. ..�--... z:; intended to be aa originat signa&ue is acceptable. Ttie;�ignabuemuist�°ii�hai ofthe F al�� "-� 3'137 DtA'Ni�`+DF31\JE; Exglosives Licensee{FBL)ar are�onsibisp�son ofttie,FEI;.�:,I,c atiEy;t2ia2:��a e .: r�.=�a,-: .. c af a lic�se or umit issued to the li �'U::�'�: « ZEPHYF3H 1i;t�S�'�FL 3354y- ....� �,., ; ..x, .:. �, pPY P c�see or peim�tee.nained��bot�'e,to_"�gage�. ' "�:;"'"r f,;':�¢ .-,;,�:�=•,;` 'the- -;r;�-,;°;n:_- w,w„r.� i��.'�`�e's7� x.•=n s=n�,..,.;.,,��;;;;:.;kt-�;:";,, ,:s .:'-'? bnsinessoroperationss�secifiedaboveundes'"TypeofLiceat`seor-Eeain��'�-.���:',�='���` _„' `�,��.;,�r,��:� a"�:-f:y'�< l'� ;'S'a.o"`�*;a':`�:�`.y: .r,� 'y w_�r,�}:'i=�,.,w:.-" - � ::t�+"1�i �iS''' ame"�-+s..-v�:.i�'�',�rtf `F,�,.:. ::+"-4xx;yM•`"L't� � r:G`F_:�'c.''.".�`i�- " y ^`a'"+`'�w�y� :c�'3"�:�.+��,reja"'�".i'""�''�" . " ..,�..,.�:�=�<r.+.y.,: ;" _" J2',f � LicenseelF'ermittee Respansible Persan Signature Po`sitioi�TifI,���`.,�''�.,f : - ,. _-^`. ,�_'�_ __�-_ ___..__..PrintedName ._ _. .._�.-----_._._.____._. .�...—Date--_f.-----._�..__..._ -._ _... _r-.----_.__.._.__.______ _. ,-_.-ax���saoo:ia��oo.isp�cci FreviousEdifionisObsolete x�hx.mxwntina3�arowuotu�E�ri��Raaf�w-sc�ms��nqi,lmsa�+uEAafacvtusmES RevisedOctobes2011 Federal Explosives Iil ense(FEL)C�.istomer Sernice Infarmation Federal Facplosives Licensing Center(FELC) Toll-free Telephone N mber: (877)283-3352 A'TF Homepage:www.at£gov 244 Needy Raad Fax Number: (304)616-A401 Mattinsburg,W V 25�1Q5-943I E-maiI: FELG.�a atf.go� Change af Address (27 CFR SS5.54(a)(1)). Licensees or perrnittees rnay dur�ng the term of their current license or permit remove their business or operaYions to a aew location at which they nrtend regulazIy to carry on such business or operat�ons. The licensee or pennittee is requireci to give notiScation of the new location of the business az apera#ions nat less than 10 days grior to such removai with the Clu��Federat Explosives Licensing Center. The license or pesmit will be valid for the remainder of the term of the original license or permiE. (The Chie�FELC,shall,if the licensee or permittee is not qualified,refer the request for ain�tted license � or permit to!he Director of Tnduistry Operations for denial in accordance�'8►§555.54.) � Right af Succession (27 CFR SSS.59t. (a}Csrtain persons other than the�censee or permittee may secure the right fo carsy on the same eacplosive materials business or operations at the same address shown on,and for the remainder fthe term o�a ourtent license pr permit. Such persons sre: (1)The surviving spouse or child,or eacecutor,administrator,or other legal representative of a deceas hcensee or perrnittee;and(2)A receiver or trustee in bftnkruptcy,or an assignee for benefrt of cred':tors. (b}In order to secure the right provided by this section, he person or persons continuing the business or operations shall furnish the license or pennit for for that business or aperations far endozsement af such successia to the Chie��'ELG,within 30 days frarn the date on which the successor begins to carry on the business or operations. (Continued on reverse sideJ Cut Here�G �— _______________________---- —► . � Federal Esplosives LicenselPernut(P`EL)Informataon Card � � I LicenselPermit Name:HAYE$,JQMI�L DAVID I � .;�.;�:'ieti�a::3_.5r'a-"= 1 1 j�%ri,. I � BusinessName: ,.,...` _ r���;Y�,.�:.,.," : t ! ".•`:ij.:;� `_ _ _ "'�= 1 I j?i:: 1� ..:y;`'°*`.:�t:., ' ';c'.` � � .nselPermitNumber:l=EL-'';tA1-54�G-00866� � I _ - i:: � . � LieenselPerrnit Type:54-USEii';OF�,EXP.LOStuES � � �'�v:.w.-�:w,,:;_,".�:s%:%'" I 1 - , - . ( � Expiration: July 1,20�6 i t ► 1 Please Note: Not Valid far the Sale or Other Disposition of E�losives. I t t U.S. >artment of Justice �-- �- - °�Fedetal Explosives Licensing Center Bur ,f Alcohol,Tobacco,Firearms and Explasivess�'�_<_=�`r`�Y -_::`�-�4�}:Needy Road QSl3Ql2013 Fede "�Explosives Licensing Center(FELC) ;�;�.�`,�:""-`--�``.'T : �� Mariirisbnig;.West Virginia 25405 wrvw.atf.gav :�-;,�' � � _�_ telephone:�"(877)283-3352 fax: (304)616-4401 --•, N;Q`TIC� OF CLEAF:��1�I'CE for individuals transparting,.:shipping, receiving, or,poss_essing ezpiosive materials. ISSUED TO: tIAYES,IOHN DAVID . � ' . 1Federai Facp(osives license/pezmit no.:',.1-F.°L-101-54-6G-00866 NOTICE DATE: 05/30/2013 �- • ' . . Expiration,vate: Jll�',y 1�2��.6 - >. .- E�cplosives License/Pemut Type:;�¢�SEIt dF EXPIAStVES EXPIRATION DATE: This Notice expires wlien'superseded by a.aewer Notice whicit�"wili;list.ali curreut responsibie persaas aud employee possessors,or when the license or permit egpires'-wtiichevercome�first . - ' b WARNING. Only those individuals listed belo,w,as RESPONSIBI.E.PERSQNS ari8 EMPLOI'�E POSSESSORS witth a background clearanee status of"CLEARED"or"PENDING"are authoiized to transport,ship,receive;:or possess?e�losive materials in the conrse of employment witth you. -.._� , :.- . .. - ,.- ,, $ "DENTED" STATUS. If an emgloyee possessor-has ai�ackgrou d'clearance status af"DENIED",you MUST take immediate steps to remove ,,..�.�_ - , : , the employee from a posiHon requiring the transporttngY:slupping,�eceiving,.oc piossessing of explosive materials. Also,if the emptoyee has been Iisted as a persan autharized to accept delivery of explos�ve.matierials;.you;MLTST.'remove the emplayee from such list and immediately,and in no event tater than the second business day after such change,notify-distributors of snch change,as stated in 27 CT'R.555.33(a). =ax :^c,:,.°•�:� - - :-;;�'-f=�".- �, ._ , =;�.:u�. :..3�-u,>�-��=...r ,��_ .� ,"""y,�.�. ,r;a�?�r'�``-, .�.:,. QG - �I�:z_�..���}�'�:±"si'.�..���w�� �'''�. �r�t �'+�.ri.,,;:�,x,-r^ssr<. CHANGE IN ItESPUNSI$LE PERSONS. You MiTST ,K.,,,��,�;. _,�:. ��,::�-.� �,;::v,�, �; ,�s..,�;�:.��,'=�;=:_:W �°: ���;;-�..x�:��- �;=� ��.',�•w.t,.- , � - <":�: �;..3Y �.,_::;�,,,.�,n-�::���=�::x, s;ti;:-✓:2;ti`"".;.�;:, _,,���f•' ;��.�i�»` .. � � ;y,,.,�-:- ':�c.s. .�r_ -���.'x.�r.y:j: ,;�=r;sir�-,r>.:;}.�-�-x�:��:Si'�_`"354�`,.�','.-;v-,'=`�`Y'=�:�"=�:.���"�' ,:�;M3„'Rn�•'�:�=1.,:- s'.s+ re ort an chan e in res onsible ersons to the Chief Federal :� -s, � ;x_ � � �r��. �,{�.>���� F Y g P P � .u,=�. .�.���,. M., �<- - �.: �. r.-�y y'A�'-r.'��;•�,�,'rr�':c;Sy �T''x�•�•'^T,ra;�k,;f-�+' ?�"r'F;�..�5,+� .�.�� �a;?y�'- a,F•�.'r`^r.t-°a..;,y'��s,: y=,{�.-,'-��.,,-;'S>•,;co'_ .�;,.r- ,�:�a;�>., „.?�`..� ,3�':K:,;x_x^=� r.rtr-.'.' �"s?�,..�=.'.c;-...c3�:v`,"k:x�e*`r�,.,;r. a;�:F:.v.._.'.'3:�'�'.,"_:<?'-"^"''.,°•'�3f�,"s Ex losives T,icensin Center within 30 da s of the chan e and x "`" "z�t�;�= =;`=4 �:�- K x,;rt�'"" �:' =r`�' � �` '�':'''� P � � Y � �,:� k�*� .:�x��"���^�' :::.s� =�>"',,=.�";��.,�";�;�';�;r;c��,, :�.,.,�_.; �.�.,,�,,... �: �`�«" ; c �- ,�..'� �.�A:; �..r__,;,��:.,. r� '� .�,::x?�'¢5-,�,K'>�:.'',�r.-'�;"'s,��Y-.. �:.;,;� ,��..c,`�,.r,:€3��`'�:''�";:'�':^' �{'>.,.:�:;;�;%l,-''°�y,,�rC:,�i new res onsible ersons MiTST include a ro riate iden 'n �: �: �= '^�° ;'.`�` �a:x:: �`;�^'=�-` �''�3�`�" P P PP P � g =F', ��:-;V�,;�:s .��;,:,,;;�-�::�;;,;;<::� �.��.;�. �°r...;�"':°�r r -;� �� tt Fs 1;:c���F„�.Wr �.�' � '^�� j.v.x, :`h.�i...: ,�,.'1'�.^�n.*^a -�:;e�-��`�•"�"'!5�; f a'o a de ne in 27 SS . . F`n rints and �''"�v= ���' ��:�� �}F��`�"- �"'���"}`�~ �`"�� �` ��� in arm k u S fl t� �F'� �J l�. I g81`p -�z :�zr,. �w;;�v�=- ,;x;y;r:x,�C.r,...t��;',��.-�x,�^-:`.-�.�',�zv,��.; ����,5��,�t' :a^e-��- � �°='=::�,....:r..,.�=_ �'-�;��.. ^��-=•'�"�:i=' �•^'-�y�^"= �.��`.i�%JY=t,ti'r.K�Y�.:��;`�^^_:.'�'ri�'�.r".�.'`�v;p'„e':�'_ >,°'r".�. � .`�:r'.,pr,•yv•.3`--•>;,; • �*�'�, . ,,a_•?'�m:.-.,^.?p".!i: _9'.�' ,�""'�,... auY�a photos are NOT requ4red however t ey witl e required upon u��'�"'�{�`�-�,�' ;�='�•=-�t�:��` � �''��'_�:"="""���°"`-T�*~"-=.�'� a h b _�.�- ��. .�,�,�!I; - _;�~=. ,�_��.,;;.�;- _ r =�''�i° �s^aa'05:;4"e,; �+'.`°:.., ,;�•=# :-�"vs�,r,;<,�+:.s'i »,a:' -a�-v�a�� . .`�.._ �:.,.' renewal of the licease or ermit. '�.:r;:4�"';:[3,��.=�`.:.:�.-, ,-..�., t.y.�r, ri��r;:;�....r..,�.�,�yy`'rY,r�>y"�a,��'a`�xx�fN_,,p, P s fr�.i1��''w":s.�' �gCF �,t�f�'�-.�r ,,.�.��',:.;; _�.*�.y.n .€%-''"'-"-.,:' :;�;r�.'"ycr�:.$�'::�. .�w � �s..iL,i�JY�Y�%;�^::....�,;YS:e's:.,.���:°;xrya ���,,�,,�!'-K'�_w,� '..;`,�....:-,;>; ,#��1'„3Tc"4;+�' .-.�i6u��tt- ._ :�r,ry_ �u:� .1���T•.:""�i,'w`r"�b.''=�.-.::-;.. : .hQ�.'� �:'i+'J:,c�F-. ;'�„ %'�z `.,r-�f �yy+ti's.;r.ti„;.'`:M':,.,,��%.;�'z°-,e—�-,`.'s' :r�''�s',;�-s!'.%:k' '^`;�3.,��,�.�w. {},t%f,'1's � P"��.:r ..�; �, ��s�:cc ,�"�,.',.��,�m� ' ' - -� ° CHANGE OF EMPLOYEES. Yon MUST re ort an chan e <M�;>>����:�;n���s:��`�=,:k=:=;-�:���'>=fwMe1;�;�.:N. %=�.;i=� ��:'r�`:;�F�-'�� �-�%"�" , P Y � X ,:�. ,:�..��:,�.:.�.,�:... ��;� 4� � „z,�, ,��,;�,, -�:,<..�v,� >�:;�; ;,.�:�' �� �° _ � s�w�=:�R���•._ �„� �;;,.=.T�_.,.,�".Y y''"u y�g�.+4t,�.w A >r.S.� V�t-". +E.-���:..w n� �t..w.��. ?o-d'.-`..5 k+."^S.N of ern la ee! ossessors to the Chief FELC within 30 da s. . ���;'��~x _ �r:^±��:`<-�`�,`.;- ,�~`�i,�;;�=�„:��:;,^.��^;.:.,:,� ��<�:t.,�� �:��,f:;�;:�.;- �:.����;;�: =�. z�. ��F,;. � �:��,.,•�M,. s.,�.::. �:,. P �' � > > )' •..,-'.,,;? c` ,s °r:,:.-R-�>.F,:.,�..._r,v,x,-'. ��z.:�„_, �''�".�,� .��.�.'-:er _��'x g.s�+ K'��,J�;:;;:�. :.,a.. ..s,;i"s;�� r ' s' `r";w�;<, s,;. %i�� wa��_ �;i r�,"� ,,e^.�:-;;.., � .C�'r_., Z=-3r,;," y"�° r-..p, -�...,r-.,._ ;ry=�"'�� ,-�-. �r �y,'� vt„ �- Re orts relatin to newly hired employees must be �w<��.-r ,�-.;;:r�;��:�;�='�::���;;y�:=- -�,��:w,�;`��:�:�,�.t�:�-�,:��:i'r=�.,�;w` r e��._:�:�:� p �a �.'�z...w y�e'�;r_-r-r�.�r.�+�.`-,";;, .wr;*.'-,r�rSt`- _ :z.'.�i�����`"�>,3�:,,��r'�"�'x����}��=-='��,t,,; _ sabmitted on ATF Farm 544Q.28 for EACH emplayee. Y':."�':==�'4�='�� Y��'r _ -�'"�=�-'-�'_� "�`�'�='�-:` .~'�=.=��`,.,�.'=y'�zf'=-�,�-`�`�=-.`�=.�:� I This Notice of Clearance'is provided ta you as required by 18 U�S.C.843(h)and MUST be retained as part of your permanant recards and �made available for examinarian or ins ecnon b ATF officers as required by 27 CFR 555.121. If you receive a Notice subsequent ta .___.,.___ I P � Y - -- -- -._____. .__ - - -- .�is Notice;this 1rlo�ice will no lottgerbe"valic�i`.` -_.._ � ._ __._ _ ,_.. ....._ - In accordance with 27 CFR SS5.33,Background Checks and Cle ances,and 27 C�'R SSS.57,Change of Control,Change in Resgansible Persons,and Change of Employees,ATP's Federal Explosives Licensing Center(FELC)has conducted background checks on the individual(s) � you identified as a responsible person(s)and an employee/passessor(s)on your applicatian,or reported after the issuance of your licenselperc�ait. � II The following is a SU14�MARY of the results af the backgrouud ahecks canducted an the individuals you reported as respousible persons and employee/possessars. ATF will be notifying ALL individual�listed on tlus document of their respective sta.tvs by separate letter i mailed to their xesidence address. I � PLEASE BE ADVISED TH.AT IT IS UNLA WFUL FOR AN i PERSON REF`LECTING A STATU.S OF"D�+NIED"TO '� TRANSPORT,SHIP,RECEIVE,OR POSSE3S EXPLOSI MATERIALS. � �Please carefully review this Notice to ensure that all the informati n is accurate. If this Notice is inconect,please retum the Notice to the �Chief,FELC,with a statement showing the nature of the error(s).�The Cluef,FELC,shall correct the error,and �return a corrected Natiee. � _ . � Numbe�:oGRESPONSIBLEPERSO�!!�(�). : 1 -�.:��-;�.; ''..coitt.iinued : "�'�� - - - -°"=�'-" � :°��:�. �:Nuinlner::a£EICI�ALOYEE P13SSE8'S�:E2'S: ">.:-� X' . $ -��"s ,.,�.:::-,:°:..> �. ,,.�. . .(. ��0. - -- 'r�.� _ - _ � -- . _ _ , ._�I.r ;.�:,. - _ ;��°,, _ ':�.�;���:r ., :�:r; M}.',., - - ;t.,:.; `i' � - - °ck. ..x: "}'*c" <.r,.., r�.. '�, ,.a`.. .;,.,t;��:� _��x.-:,,.,, _ � - :<,�,� "AST NAME.Fir§t Name.1Vlidale-Name �Clearanc�Statuis.� ..�! .:`K.. - ��a''" ^'Y47n;v:,4�- '7`" _ ")_ ^,.�.;. - n.kv<%1;=?.,,,,".=;i g�I..A5���1l2E`�'irst�Nam '°lVliddle?1V"axne��'"�'='��Glearauce�Statiis�;�;<: =z. :r .F:�::�$�> - - , �:�.:7 .r- = s ' �? �:�."�.r E._�•:r �,��.. _ . _ <:�. _ ;;'� - .r`:;;.;�:; ..,y,�r�� ? ..:h%c:. - - ��i� 'M=�F„_ ?! -;.._%x,. ;,E,s�... :�'s . 'S'1.� w,�„Y�. +G" 'bi�c'�i: � - ;'�=;i��+,- r�� - b»t_�, � �.M r_ e N._.ij+y ':{•. :Y,,�a .- �`,�i..,;-�� 'vj.�,�:'..?�. •�;i- .�''*.� �'� �.`-�sTS, ��+[r ('�`��+ /'� ��3� 'Y _�:'�+.+.,.... ' - ,». � g - ':<tT`',T`,� '..''-"t'> �-3 ::;*� •�'v '>F`?�`y�-3,..'r:.,, ' sv',f:"=;�. IBLEPERS`� NS•,� - ;,>- -_ .g_ ,�,, il�:t'l7 �ifl'�c7 l!-. -.:��-'° '��` �`:a.. ':�" i� - ,y'=�' _ 8 _� - y:y:!` _m;;;. - • ,- - • '';�' •�r�-. - ""=i.'P'''� ' - :.�'` - .Z3s -:n''. - = - - i v. ,4� ••j. _ . - _yt, _ ' -._ t�t`� i.�';..-_ ` ` ... ^i' •.'�'v`=:. " .,,,' w- _ _ � `3.� :'--I.A . 'j�i. . ;,�, t.Rt �1::1_ :t� °^�:^:?-�� �rx�,G�r(V - . : ,_0001 HAYFS,JOHPtDAVID' - _ �ieare�::. '-' _ _ _ ��#'`� . a. - - - .�;:,.;```�'. .. ";t'�~-;::.., .: _;:.;.�°: :'�s: "��= r�• - - :N;'.;`� . �L4� ' - =S'^µ�^:i�'." �rF:.:i'. `.J'` _ �fJ " _ �7 . . ^iF<•" .�{L�^s �'.'^z;is•'<:i.;_°. s`•j:• a:.l::wT,,s�, II ^4i+: _ �:�k'" '.'�if"� _ ��:F}'Y ' '�`''iVll'I:0`I'EE�POSSESSORS:� .,�,.��:.r 0 :��:- � ;�,;:u':=.. , ..^��°.t�_��'"=' . � _ "^.' .:.3., o'.�a si1�.'.r� +. -�. 4-.•.: 'wfiJ*,.w��:.".:µ;� . ,. .�._; il'(:a> _ -? .u+m..'�,=� �...-.,-....:,, _ _ _ _£` .yyv.T ,-t.n^,?�„i:�,x-ii��_ - ' - : .: - �,�;` - -�,�e�,`.' - ... -�i.,>. - " ,. - .y�' ' _ .. J>r - .. ' - _ _ ' , ... ..,_ ,.W.: ,. , - . . .-:� . - ,...�.::" . -.- _. � _ ;� ,.-. ..r. _,.. K..-..=,-- _ .r_� ._ �.>.-�t�:.;� _ �.._q. .... _... _ . � _ �;.,�.... 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'Ry' _ _ a;%3_ 's , , ► -�J David Hayes PO Box 860 � Zephyrhills, FL 33539-Q8b0 i June 29, 2015 ' RE: Fireworks display, Skydive City Jul 4 , Dear Building Dept: I arn applying for a permit to host a firev�arks display at Skydive City on July 4. As required, here is the list of fireworks to be used. • Galaxy Eye Opener Cake i I • Crazy Exciting on Steroids Cake • Winfier Blast cake • Immortal Flame Cake • Gloriaus Galaxy Cake • "72 assorted 2" Garilla Shellslmo ars thanks Paragraph Paragraph Sincerely, � � � I � � � ��� J. David Hayes I .�:�.;'�_� �� � t • Ty,fi[.�N:�'" „ i�j± +���y� �� '�'�Y4 �'{�`iA`*'� .pt;, •r� % ,D-7'° r? , ��' � � .�`;'i,;; w fix�.. .+"��, -��, y re.4 } S~ �a ��g. �y. �`w �.`x' p' .�r�; RP .�y�..yv, l fr' � ;����,.,- .,�:= , 9 � _ � ,,. :,�: �� ; �� --� v r ���v"'� i"" .F[ :., .� �;Y"t _.4. E�. �� �'�t§k�" � Y-'' '*'s�;..°c.. �` � o .� J ��:'�i� 1 `' � F." 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