HomeMy WebLinkAbout12-13730 CITY OF ZEPHYRHILLS
, 5335-8TH STREET
�si3��ao-oo20 13730
FIRE WORKS PERMIT
Permit Number: 13730 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:
Date Issued: 12/31/2012 Name: CITY OF ZEPHYHRILLS
Total Fees: 500.00 Address: 4241 SKYDIVE LANE
Amount Paid: 500.00 ZEPHYRHILLS, FL. 33542
Date Paid: 12/31/2012 Phone:
Work Desc: TEMP SPECIAL FIRE WORK EVENT 12/31/12
- A;� �c '�
- Z�
� L %-�.�� �
Chapter 633, Florida Statutes,authorizes the City 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 related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of$100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"FIREWORKS" per Section 791.01, Florida Statutes are considered as any combustible or explosive
composition or substance or wmbination of substances or,except as hereinafter provided,any article
prepared for the purpose of producing visible or audible effect by combustion,explosion,deflagration,or
detonation.
. � 1
CONTRACTOR SI NATURE PERMIT OFFICER
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOURS NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT- 813-780-0041
�,
� ��� �� """ �� Cc' �' ►�' ``� �
�)
O (' � � � �, f�� � � -�
� p �, � � �./? �c � `�1 C�_�
�`t� � �� ('r� � --� � � r� �
�
� �� � � �� � � r �
� c `� � c� �=- � -�� � �j•
�
� � ��� � � � � � �
�'s � � �, �t � � + '� t
� �� ` ,� � � � � ��
� -p � �. � p � � �
� � � �� 70 � �.. �. �j /�—,�
�1 � � r � � � �
� � � � R� � � (��� �� �
- s
� � � � � � �
�� � � � � n �
� � v� � �, � r-i`l
� ,� _
� � � �
� � � � �
�� � � _
�, �
Jacqueline Boges �� �� � b
From: Bill Burgess
Sent: Monday, December 31, 2012 9:50 AM
To: Jacqueline Boges
Subject: FW: Fireworks display for Skydive City Dec 31
Attachments: Skydive City Fireworks.pdf
From: David TK Hayes fmailto:tk@skydivecity.com]
Sent: Friday, December 28, 2012 11:14 AM
To: Bill Burgess; Verne Riggall
Subject: Fireworks display for Skydive City Dec 31
I attached a couple things in reference to the application for a fireworks display at Skydive City on New Year's
Eve.
Application filed at City Hall with a rough diagram,but I also have the attached file wit:h my credentials from
ATF and an aerial shot of the planned launch location and spectator lines etc.
We are skydiving at 8pm, l Opm, and right at midnight as well so I expect I will launch a few prior to midnight
and the remainder after everyone is on the ground and out of the way.
Consumer grade 1.4G fireworks ONLY will be used, I have plywood platforms I use to set up and launch from,
safety goggles helmets, etc and it will be only me out there unless you OK a helper to work with me.
813-598-6981 if you need to reach me
David TK Hayes
PresidendGM
www.SkydiveCitv.com
800-888-JUMP
i
. r - pE�lT3�#�Ilr'J'/T�7taE,iti�l�!'l,�f _ k : :� ��%ax'-,:.���:y
s_ ��j � �y.ky-�'.�"a'��,„a �_..° ''r- a'r.. �-�' � �k.,t .,
.'kp�•," ,tY �ruC`=sa - ..�, `,
�.„ f, _«�;..
v �'� `
���p��: �� .�, .`�.�,.. �
-2 ,�Z �.'n ..j�
^yth
4''" :a?:�.`j�
i
;.��:.�.. .'�,,}; 'a�r�S.;';;::�.,.:- .nw �.
�' ,,�:' 't,wS3�'R�.r'. %'«
, ;1��r,.'�"-'.„: S'". G T ,
� � 7€•��f r£ � , � ,.i,�.,f , .. ra�- .�
;: , .�,�^wr` ':..z,_ *a 3� .� e .'
�+��, � k, �g r.,a . .
_ ,y..3 �, _�"+�Pa y '�ct"i�
S�vG�.� 9 �. �'��,,�" � eg�� ���,G ��'� • ��.,
„V+.��`a yyyf �.$_ . Y,-- k S _
.� -y�. �.
y f'n�� �
.. - �?�,��:-� �:�';�:�t'�
.t r`:��'���,I. ;.;�,` �er: , , - '
,'., : '„tr�vp �`, -
• ''�s�Xi,.�;Y'Y�.'-'.'�r"Lu %'�rx� - _ - .a� .
���;k,t t�'�� 4,�,K'--i.. _ 3 ��MY!+*+Y
`M ' y �3 � 5s �.g'���,5'�ar-�y�",�., �
`Y "" ��"��'��;:Yn& '� Z- .',"'^"�'"` "'� �- ,� ��� tr ' '
, ' Y' ,u�'�,.,�� ��..°` �""�»+"�.,. � -,}-,� '� ,
, i �a;�a�",y�,��t�x ;�� �, a�= -
""� � - -
' � � . ' rZ� 5;��,� ,R �� - � � _
' � 'V.�,� „�,� ' •• ' , - ;
, " i��¢����'"7�fi'^c"�'y�9
' ,y y�. �,�,..�, Y'd x - .'
, ��, �.�-'�7 v s
' �.,�v r . ;- - �a"� � �",�t@F-' . . . , . , ,. _ ,p.., ' sk,� • •x w t . :7.�` . �> , . . , _ .
' .-na:. ��k,���"� , m� ,,r ` �,n - r - ��e - . .., ' ^ ,; - —...
� �
Lr a
. - _ p; �M� g' y �� ° �� �'.,� � _ 4 ^'�a ��^-�—�A,y,�m�.y� ��'^� �� ` � — � ; '� y „
�7}��� t�N�+.� , td'- y 7�S,��vi`i.s� "'s�rk�' 4`.�'%�_Y„{�' '{�3sy..��t'k' Y _h�.}�P .Y- � �•q"�'�� �.,d�o�!
�� ��� +
� ?'
����'�"�'�`.;`�;�s*�: ° H��'° �'Yz. � _'„�k`��s� 3 v_"''� �, _,��n y �� "'� � „ �.r. `. . „� , 'a'" a�.fi�,'�� ��'�.t
�...Q.�B �'� ,r�, , i
� ' � � �£k�k'St ' '� �4.s 9 '1;`. � � , -.
. , _ `'�s "��,.��y" ti Mau�-�, � '�, � x°g ..�� s. �' a� - a�"^�' ' . ` .
� A �„� '>� rr 4 '� '��s � g'� r ;S ;�''�° ' '�. ��4 1 , - , . ,
' y_: a, �3 . x ����r��� 3''h .� � ,� k' e 7"T �. ''�_ . ,
' .�' ���"�`�.�' _ F_t M 'a ' 1 4
: �-�� 1'� �- , ' x��h, r� w.��-� s ,�r r 3_r _ - -z �, �' �3 .� '�'u'�� - .._ .
E'" "` w ':t �,"i, ,t r �����°'�,�, ' �"`.�a�'.S - .�r��-�.,a#.b` ?,v " ', � `r �y _ �'' 'i""`j�` ' -
� ti $
� ',Y".� � � ��� f �'°k� '��aCM �*' ''�<� � a ����"SP�{M�.n s�'��k����� -..k"�' � � �, �r'�'��� v
t a '�t'.`,�s•��£������L, x 5..,,r c. ��' er � �''-s-`?-ix,��c r�.;+� y,�kd, �,+�.� w � .��a ,.,•� n _
�'���s- f .�, � .�-� `"" �q R �,,,,��.�' ro+a4 d' 7^s x x. Mz
`���"'t:' t � r+��,�``�`�`�.rw� ����'�y�`r�� ��r :Li,F�'E ��Y�r' �s1�y �-�a.���_'�+.�
� "�, /f_ ,,,g1A ' 4 s pw:- SF? , - . � � � � � '���,' L�'"e. ('
L Y
i. , ,a«s. , ar��'� 1 . -.' vNa , 3i� °5, ,� -�'w,� - ' '--- , , __ "� q - � . . .
'-�. �a �� - _`k� �,',���f c.- - �€, - .
r' ��a_ k�y��d"9� 'r+ ,�;� -°r-��"^��° ,��'t a.%'.i:. �w�� 's�i�"�i�"�� �-'�'�"a��s,+�}M'.ryyr•��k'�' � °'+„
` �+ .r'�"�"'�` �,� �'.� � _',�'��tr sTM�� a �,,C'�+dk � �'°'�lt�� � ,,,z-� . .
,y� "�rt�Aw '�"^r'�� .*� ,�"'xk 1 '.�°'�.a '"�c`3s i 4�' y,�k �iptR�� s t -as'"�.w. �,�',e, +� "-�`+' � '} '
# "a' a� y. � '�¢'�` 'S�„ .�it.�� y�`�'�$� d'4` � � � .
' _°��& � �;'���F'�a4� �� . �»� - � ��':�'v�r. � '� ,�e �m,� «- «,� .x �'.m �', � �
� '; Y ;r+�at,F s�{, s��,� z .�� , rSn'� v ^�'�£r °,fu"�` i- �
�'+ `' �!- �°+9d+�' r a�- a A � _ 's f�aw „�5',�'a 3 j�, � .✓�r - �' - 3" . r
V` 4���^�,�'� ��x i--jt�,�s�-M.r �m"�` � «r d�.-c - �5'��— ux , -*�-. . , ,
i �,d r "�e"$ }--- �.2r}�-.�?..- , �" __s _�•'r¢ .�;c e s 3�.. �:�' , , . ,
��S r*'� �tr-� �' �e .� _ _7�; �., -.�. `e , � -� �
'�. -�y 4i�'r s` � q +
1, � ;� .,,� j-. C'�"����e� ' � , ���r'" a '�'* -�'& y �Y+`-'ht`�'° y s`��,'�.,�a�� r '� Y� ', :,' � ..
A ,
+k$, $,,�r �"r ��,� 3,.M. , � z�r��-r���7�iyw�-X�1'�'�w��-�� �,�'i st�„A�,�,�y ��'i � , '� °,r-a -�i .
x � i i r
4 d},4�� � I^*" � 5 � � w �-+n'�} s a u�� �5}����-kt�'�'a f � � �rta�i�'d.�'A��'w '.`�".k�x j� r< ', I�" t_ y ,a- fi ,< <
�%' - - C� �,.t i x q� 7r$'�.��'� �y,'� ,q �.� -,'� '1�°'y � _
�� �1 � *.-,� f�„ iry� .�. 3"",�, �"�.�' _ _�-' Yy�Pn, ,ttL�,yka� - � - _. � - �' �5. �
{ q [�' mf +�s 3„� -,'�°M�y,, -� '}�s.$ �!�,� a,+e 3 �! ''� .{��. 1 �- '�, i
� ;�'I ; I! �� YW dP�$�� ��rr�° ,�'w3,�i',MG '��, ..1'.,�.�'A F �1 y d2T' �f'� ,fi }�.� ,rF �n„ - ,
z� '�. ���: - +� � � .eR y,r� �� S��i , ,' .�`w, �i
"� V" -`ri -�Sti��s`' t a,• • �; �` �'�x '�" . �r w� , • ` . . ,
. :{{ . '7+ h'�� -4..{r gf����y� - � jA, � n A. 4 �1-, .. �
,i .�i'� '�� '�'� M�Y} � � ' �
� � � �5� JTX'N'y�$A�."�, „ ' _ � r. � i ^ , . i
'n �'b7�WY�.k��E.qaY' ��� #ni � ,y �� ,,, t.n�:� rv . � , 1
�� s,s W".�ys, "*�'t-o r'a,.r r,r`�h�`� �y � ' - ' .�'�- ,. .,,
.s 'i ��'` w�z;�`�€�,,s��,,, ,�`� � w� �; �, .R ��b t" c .�'� � . . -- , � , ' ' ,
:�, ti� �,�'a , .„ �a!� ��— ,� �� � �� �, ,
o- �'',-LT� ,��M'�rE ,� -'� � ��� ,����' r� � -� �' �- � � ' � � , � .
�°si d a��.� � "��1S^� y,.w��,� �" kz N,7-t"y-M � -r', a ,��_ 't;� , , t S^ , ` r4 q `�,,, . ,.
a6`��,g � ''�'a��,��.�a d�'��'x s��'`,�a�,i r f�,�?'"" `k' ,.�,�a ±"-�' � r�,'°`�'q's„ .. - ' ,
«�a t d a�, �°�'"'y��d�5[r�� �.y,�,� '�� �'�' S ^�-�. ��, -'�3' ,�, °# �f t " � �� i, �;� - ���� �r '; _ , . t, , `
^ "�r'm'`5,,��� ��y�'"'k±� i�y✓' �,-��,..� , :�d -J��+' 1�a- "Z °S'+�"��C A'ifi ' _
���' yi.. .w a�1' �u i"�� _T- Y' t L�` 16 �^'��8! ..xp '��- i"�-tk- - � . .
.s= � . Y. ,£«w 4,�y a�.�d§^s>^S:P;�r., ,y- � _. _.. ,+. �-.&,: �.. . �
' 3r,
� Buaau of Alcohol,Tobacco,Firearms and Explosives 7q4��y R�d 06!'_5/?010
Federal Explosives Licensing Center(FELC) Martinsburg,West Virginia 25405
www.atf.govi celephone:(877)283-3352 fax: (304xi16-4401
1"�1�OTICE OF CLEARANCE
for individuals transporting, shipping, receiving, or possessing explosive materials.
ISSUEDTO: ►u�s,JOHNDAVm FedcralExplosiveslicwse/pamitao: I-FL•101-543G-008Ci6
. E���: �ut� 1,Zo��
NOTICE DATE: 06125R010 Expksives LioensdPeimit Type: $�()$pt OF FIREWORKS(DISPLAl1
EXPIRATION DATE: This Notice e:pites w�eo superseded by a�ewer 1Votice wYtch rviil Lst all curreot responsible peraoos and empioyee
poeseseors,or w6en the liceese or permtt exptrea-whichever comes�rat.
0 V1'ARI�'ING Onh those indi��iduats listed beloN as RESPONSIBLE�'ERSONS�nd E!11PL01 EE POSSESSOI2S with a background clearance
staros oi"C►.E.ARED"or"PF;NDItiG"arc auihqrized to transport,ship,recei�e,or pussess ex�losi�e materials in the cuurse uf emplo�menl��ith
�ou. '
B "DF..1�IF.D" S7�ATUS. If an rmplo��re pussessur has p background clearance statuS of"D�NIED",�ou M1fl'S7'rake immediate steps to remo�•e
the employee trom a position requiring the transporting,ship{ung,receiring,or possessing of eaplosi�e materials. Alsn,if the employer has been
listed as a person authorized to accept dcli�cr� of caplosi�•C m�Ceriais,}QU MEISTxrmove the employee from such list and immediatel},and in no
e�•ent later than the second busi�ess da� after such chanke,notifi disfributor5 of such change,as stated in 27 CFR 555.33(a).
B CIIA:\G� IN RESPONSIBLE PERSONS. You�1LST ���: ����=;�� —! �,�"�''�;.�>,���`�x��• Y�'`�- `°`= .
K'T'"+'3.' Hj�n.�. Ae `niqMd�+�M �N� M1� M N _ i x,e
re ort an} chan c in res onsible crsons tu thc Chicf,Fedcral �^°�'��`�'��'�'�"$`�°"• ��� f.�„��rt* � �� ��R`�`� �e'-�'�4
P � P P `` �,.�� ���.�..�.. .��� '�°
w H .��� �� � � ;�r
E�plosi�es LicensinK Center,���ithin 30 da�s of thr ch•anke and � x����� ��'�W�*�'����mr�r„,,,,����„'„`� �f°`� '" '�"`4 ,,��
� ��,�
. . . . . . . - r _.
�i:�',
�.�..o-��..
n
_ .,.ro..�:r.
N bl rsons M �S7 �nclude a ro r�ate�dent�fi•�n - �f���: ,-"���"`° ��'� "�'"�" `�'�"r���'-•� .�.o��«�;ri:
ne respons� e pe l. Pp P g „':�,��.;:�:�;� �,,,,.,;�; ,�:::, �.m"`;�'`_.,-„M. : � _
information' as defined in 27 CFR 55$ g p =:��^� e�t Q - ��`�-- s��""f"�'�:,�,.« ^a��- -
.11. Fin er rints and �- - `, ;,,,.:..��,.><. . . �-e����,�,�..�p��,�ar��,.,.
� �.:a�.>.t.��;;�;;;��a:s;»�Y r.,.m,..>��:�;:>;.'��,,»�«n���'
,�A" R1YZk3 ,�£tK L��«hMyYV-.:.� . .� .. wn.m.w?n,rm.Y�.
photus are'�07 rryuired,hohever the� ��ill be reyuired upon ��� ��«,..�<� KK;,'�b� .°^� .°�°,.;,;;,.. .;
.v�;�<":��R- , . :�.:�n.�',�:�=
reneN al of the license or permit. ��„ � - �;��� ��������R��'�'°'�
.r�.: ��.� o, '".'�. :;�'�;;w„�. , ���-- :>:ka�w.�`�a.,.
.�
�_ ,.�� ,���;,� -w�;�.o�.°��°:
, - .,�,..,.
, :.;..,.,
O ,m. ,�,.._�;�,.. , g � -
..,_..: �w,:.�, .
�t,_ �������';� :�:� r�,���.�,
CHANGE O�E�1PL01'EGS. 1 ou A9UST report an� chanKe - `-_ . -,�;t.���_ ;,�,� ,.�. �'"�a<M_ �'.. „�
�:,��,>.a��c� -�».:-.;�,�-�����::�, _ o `c.�w..�:.�;'�3:bt�'.''�:�,.�
rq:.�:°'�,��i:o.��.,�«r�:,e.�:�.a.�a:;�«�,.:..
of em lo��ee/ ossessors to the Chief,FELC.N�ithin 30 dars. � _� � ��`� �^�-t�- ��������<�- ;�k�.����.� <,�,•�,..��:,
P P �:,�..�:�. . .... .��;..�.�„ �e:�,����' - :�,�.�� �. .,.y..,.,,,:tM
�••��u,-Maaas#�-;x� -.'��. ..s�`x:� _ ;xar�i�.r�:au&�r� »a,
's�3�an�r." �x.o� 'Sx'S^"".i�^na . i.9���;a.{wg,s»m;t.,,.F,,,.
Reports relating to ne��h hired emplo�•ees must be ,,�.,�,� ������;. ;,,�����._ .�,a��.-.m..,:4�::�;;;'"k"°'�",:�;Y;�.;;��,;�p��;.,�,�,:,w� ;„
g�'..ws,n.f.-...,i`t�...a�.r.+�^mw.r s..n�E.bn.n.v�sU� 'ws,SL ,±."+t�wrt�a.r���wfe's^P+F��, M.aw
submitted on A'I E I�orm 5401IZR for F ACH emplo�ee. ^-^°�
This'Notice of Clearance'is provided to you as required by 18 U.S.C.843(h)and MUST be retained as part of yow permanent records and
be made available for examination or inspection by ATF officers as required by 27 CFR 555.121. If you receive a Notice subsequent to
this Notice,this Notice will no longer be valid.
In accordance with 27 CFR 55533,Background Checks and Cleaiances,and 27 CFR 555.57,Change of Control,Change in Responsible
Persons,and Change of Employees,ATF's Federal Explosives Licensing Center(FELC)has conducted backgmund checks on the individual(:
you identified as a responsible person(s)and an employee/possessor(s)on your application,or reported after the issuance of your
licenselpermit.
The following is a SUMMARY of the results of the background checks conducted on the individuals you reported as responsible persons
x and employee/possessors. ATF will be notifying ALL individuals listed on this document of their respective status by separate letter
�mailed to their residence address.
9
�PLEASE BE ADVISED THAT IT IS UNLAWFUL FOR ANY PERSON REFLECTING A STATUS OF"DENIED"TO
�TRANSPORT,SHIP,RECEIVE,OR POSSESS EXPLOSIVE MATERIALS.
d
gPlease carefully review this Notice to ensure that all the information is accurate. lf this Notice is incorrect,please return the Notice to the
°Chief,FELC,with a statement showing the nature of the error(s). The Chief,FELC,shall correct the error,and
`return a corrected Notice.
s
° N�;� SPONSIBLE.F : � ,-.;F ,��_
.
> �.
a =�.... ,< .. . � k, r� ��ued �.��:.° ;�:x.�.,
,� pD�b� LO E � i . .."�. °�'""�• :� �y: n�
�1�1 �, a `a -
� � � : � ,z,� �;� ��
, . ...
. r . .�,,
�t.., �. . �.. ..�n-;.
.. m ��
# _, . .
�.:'� ;�.,
o �.. ��,
`�'� °�° a:. � :av.a.
'�g =�',:AC��NAMF�,;;Filrst. �i3�e�nie C tiC`"�'t�i�
¢.,k.A ;�`�r� flame;,�11��d1. ` �ra ee�ta �'• ,� �� r- £ .r a
�� i �t.. .,� � a; ��� ,�_ ': > � � e,_ , °" ' . §' a '�".`�.
- LE R�S:�. ;��: � �w �. } � �`- ' :; �� � �mn M, t:
,� �:•��.
�. -�"��=,.,,�. a�a� °�;�� „ „°�" �; ..��e � _ '�, .�?�� ,�''� ,�F �� ° °�, �
b. �.. `l,�y, � �` +z...�m,. .+u�w9' �.�¢�^ �,.l.r '��.,.� .. s� Ffi
, x
" ae..
� �
HAYES.IOFi�1�1� ..�.r .' , ��
.
n:
-�. � �.�..,,
'�-�`..�a.,dx,�..�w.•�� �������- ''�° - - �*��«,.' p .:;:�
A W .«w:�/ 'bN�b!' ...-. .'. Svam� : ��'""
E_,�a. ;;�.�rPOSSESSOR�: R�:,��`� 0 ;��`�.�����.� _°��.��:..� °�°�.���< .
@
. . .�.m:w.». . -.�,.�; . m: . .«.t«;a�.'��aes.
%wa y.. " a.��°:�Ay _ ... �id'wx ..�:�'::� ... -«25*.4 , .
�y" >. :xx*�.s� ... �Z-d� fi,� t�£:`s .`idA . � x.S¢vr�..A�v>�, ... . ..c.�
� n. .�.. .� e' �s.r..6.,..y.'.a?n_ w�
u�� � ` ` Y� AC° '�y� • ` • .:& S ... �` n� P%an¢.� ` , y a e o.,.�,u
`� : .. „rm?� W.� . " "^ -..d 4 fie' �,^.- >S �� "'"- . M .a.` i.�k
� �4 ��,-'"k� 4_� »; a .��J,,.." ,� p' � _� #m '. q. q,.c�ro ��iry �„� � �''
�q .� r i •.�-. 'e!.. }:.� +y.,� �inta^, m�c: .?� ^ �� 'wa a. ^J a;ea„s ,ei'k� � � . x �g���
b�'k,u,a.r> ' ��" .��.. `°w°�...., .. . w .. s ,.+a. .. .e �,'.. �. .� .. ;d1�y�, �� .. , " ' . r... a.�-.• ..
�.� ^ � �'. ���� J�
page 1 of 1
�'-.j � �:.., .
f, aM," -�
_" R.S�w� '�� � �
• _� � �
■ -
■ �
•� r •—
■
a � r�
�., .
, `! __
y. +,s�
�_..
f
. ��� r �i �� �
_[ r� . ,� • �r
�
� F� �c ��`���
AiRPOR7 LIABItITY PQLICY �
DECLARAT(ONS—PART ONE
Company: .
U.S. SPECIALTY INSURAPICE CaMPANY Your Policy Number, uA0016734a-02
. Administrative offices: 13403 Northwest Freeway, prior Policy Number. UA00167344-Q1
• Hduston,TX 77040
�� NAMED INSURED AND ADDRESS YOUR AGENTS NAME AND ADDRESS � �ndividual
� � SKYDIVE GITY, 1NC. FAL.CON lNS. AGENCY, INC. p��nership
'; 4241 SKY DIVE LANE P.O. BOX 29138$ �
ZEPHYRHII.LS, FL 33542 KERRVILL�,TX 78028 or Joint
Venture
0 Other
,.2;:.; POLICY PERIOD: 12:Q1 a.m.standard time at our above address F�20M: 02/78/201� TO: Q2/18/2013
,�%:.�:;:� BUSINESS t�F NAMED 1NSUREp: SKYI�IVING SCHOOL
.,�,. PART OCCUPI�D BY NAM�D INSURED'S
°,�;::; lOCA7iO1V OF AIRPOR7INSURED BYTHIS POLICY NqM�D 1NSURED INTEREST
• .;:'s;
::: 2�PHYRHIILS MUNI,ZEPHYRHILLS, FL PORY(QN T�NAN7
,���'s� LIMITS OF INSURANCE, COVERP►GES AND PREMIUMS: 7his insurance is only with respect to the follawin
'`° coverage(s}tor whicFi a p�emium charge is shown in the premium co�umn.Absence of a premfum charge means tha
"��"� no insurance is rovided b the II for that covera e•
$`�'�`'� lIMITS OF (NSURANCE , C4VERAGES PREMIUM
�p'P
''�'ti''r:• $ 100 Q00 Eacfi Person
''�� 300,000 Each Ocaurrence a�PORT
�,.�.��;;u � BQDlLY INJURY AND PROPERTY DAMAGE LIABILI7Y 1 500.00
��.
'°:�::,,: S 600 a0fl
��.=•:t�.���:
'"�;�:•:; PRODUCTS COMPLETED OPERA710NS HAZARD
` ��-� $ Each�ccurrence
:.�i;.
re gpDILY INJURY AND PROPERIY DAMAGE LlABILflY
i�.�w�� $ Ste
,... r� $ My One Airccaft
�`�"`' Each Occurrence HANGARKEEPER'S LIABILITY
V., $
':a��,.::;+ $ Deducctible
�'k"�`•;°' $ Each Per'son M�DICAL PAYMEN7S
��' Each Occurrence
;�'�. $
::�;;�,4� Forms and�ndorsements attached: Qremium fnr Endarsement
' ��� 20001 20029 20053 20a31 2U701 20210 20702 Surcha e $26.00 540
�r�°yYf.�y
'Y^
:t;�'•a TOTAL POLICY PF�EMlUM 2,026.00
.st��=:
.�r�r:.:��
,�,,:
f":;:.:;
' 4'::'-��� PRODUCTS-COMPL�TED OPERATIONS PR�MIUM RATE
; '"������ Cave e licable Onl 1JV'�th Res To The Followin Class�ication BASI5 er$1,000
.iJ^;'.�1
� i,+ �!,
! .
�
` .
� •
�
{
j :�1
>
1
i
inimum Premium$
Ccuntersig�ed:
, Z0002 (08l1�) Authorized Representative
SKYA0187 A10001 15.00 ClIT-VND A�gOYF 003
Z0/Z0 3JCd AlI� 3/1IQl��iS ZLZZE8LEZ8 Wd0Z�0t ZZOZ/i£/ZZ
�,,��r,�.�
� Temporary Sales Checklist I � > > '`
City of Zephyrhills
5335 8`h Street 1 1 C�
Zephyrhilis,FI.33542 U
Phone:813-780-0020/Fax:813-780-0021
REQUIREMENTS
�,.
� Detailed Plot Plan showing setup of location. Refer to Ordinance 1038-09, Sec 4
Notarized tetter from properiy owner stating 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 per NFPA 10.
No Smoking signs must be placed outside entrances.
IF there is a wire fence or chain link fencing 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.
FIREWORK EQUIREMENTS—(In addition to the above)
Proof of State License.
�� Proof of Liability insurance.
✓ List of items to be sold at site.
Copy of Drivers License and Social Security Number of all personnel de;aling
with the sale of fireworks at the tent location.
FEEs
� $ 30.00—City Registration (If Regulated by DBPR— Fee is Waived)
$500.00—Fireworks fee- Fire Department fee
$ 5.00—Temporary Sales Fee for 1 S`two days
$ 1.00—Temporary Sales Fee per day for each consecutive day thereafter, not to
exceed durat�on of 7 consecutive days and no more than two occurrences
during a 12 month period on same property Ord #1038-09,Sec 6
$ 55.00—Tent Fee(40 00/BD, 15.00*/FD)—(*$15 00�vaived for Fireworks)
$40.00— Electr�cal Fee (if applicable)
Properiy Owner:
Appl icant:
Phone Contact:
Address Site:
Date(s)of Sale:
Ordinance No. 1038-09 (for additional requirements)
PART II. A,PPLYCANT INFORMATION
_.,;_. (�,
Name of Organization: -' � ��� � � I`� 1'� �1 �i �
Applrcant must be a not for profit entity, register to do business in the Strrte of Florida
Contact person: � �� ` ��
Mailing address: � � � � �� �1�I� � � °
Phone number(including area code}: () l3 — � ! Z� (j l � � {� ,
Alternate phone number�)
Fax number(inciuding area code): _� � � ` �O J r 2 � � �
Email address: � �� � � � I I� �� �Y F S ��. M�� ' � ��
Date incorporated: � j � �
Current corpoxate status: (Circle One) Active Inactive
Employer ldentification Number(E1N: � � l — � � (-� � I (
PART II. EVENT SP4NSORSHIP
Name of event: �1�f=,� �;D �1�S � � S ��� � � l<� D I1f�. L- 1 7 i' ,
Do you have any co-sponsors for the event?:�C`No Yes
If yes,please list:
Will an admission fee be charged to attend this event? ��No Yes
If yes,how much will the fee be?
Please note, an applicatio�t for any level of City subsidy of a special event must be filed with the
City Manager by June I for evercts occurring durittg the fotYowing frscal year (October X-
September 30)
2
PART III. EVENT INFORMATI4N
�� 2��bRi<� i� r s P�l�`� ^ -
Name of proposed event: _ (�-`��}�(�,� C_ � '7't( ,
Date(s) and tinae(s)ofproposed event: ��C- 3 [ /r Z 1 I F'/�'� "' C�1 �`00 /4/� .
Proposed event location: ,
�2 � � S�<��; D � �C L �1 �Z- r� i �-S , F�� 3�s v Z
L �� � .� ��-
If the proposed event is a parade,please list the point of origin,path, and the termination point as well
as estimated number of entries(Attuch r�:aps as needed to clarify the parade route):
Will the event require the closure of a state highway? �No Yes
If yes, a separate request form for state road closure must be submitted with this application.
Will the event require closure of a City strecdavenue?: �_No Yes
Estimated number of vendors: �
Estimated number of foodlbeverage concessionaires: Z-
Is it proposed lhat alcoholic beverages be sold, served or consumed at this event? ]:�to �Yes
If yes, a�t applicatron for a permit for consumption of alcoholic beverages»tus -also be su6��titted
a�id apprnved. (,v� �/� 1/ � � L f C�S� .��'l� �(/��� �.�-�c�' ' `"j`' `
Briefly�scribe the proposed event and the specific activities associated with it:
,�►� ��►F � �- Y P� .5'�/ �i R F,;.vo ru�C, iJS�� oP��'A-��;
(,�}�LC_ c�S j y4 ._y /VIJNL►i� S'fJ-oLU �JS rN�-
�r��vSvmF�� D � i, tiG �����o�eKS, �fv�� ,
Have you held tlais event before in Zephyrhills? No�Yes
.
If yes,when: � �-- 3 , 'ZU I CG 2�� g 2 Sc:�G �S �I�' ;
--, �--
Estimate of anticipated number of spectators/participants attending the event:
-� `�'bCa
3
In the event of inclement or hazardous weather,do you have an alternate date selected?�To Yes
If yes,what is the alternate date?:
What electrical services will be required/provided for the event? (Please be as specific as possible):
/1,^v,�! ,�
What other utilities will be required for the event?
Restrooms, garba�e cans and collection �- L, R� .�1�;° /�' ��/E �'t� .
Please list alI eqaipment, e.g. stage, tents, vehicles, etc. that you propose to use in the event or bring
onto City property, streets or parks areas (All subject to approvan Note tltat ter:ts 10'x 10'or lar�er
will also reQUire a�re ratin�certificate.,
�4 J'� P�Fl-'i v�?/vl5 0 ✓2
L v ' ; r i L �_ _
�a��i 3
(� v � i� _ G�} - /Sa�,�2s
�"�1 "�' � �� ��� �1�` `
Please provide/attach a description including a map and location and number of public facilities to be
provided far the event(e.g., toilets, garbage cans, etc.):
` i i_ L- � U ( j .)
�N � a •- D — O � �C'j >�'�S
Please attach documentation of the appropriate application for Pasco County Health Department
permitting fox public facilities.
�r��
4
PART IV. REQUIRED FACILITIES,AND INSURANCE INFORMATION
Who is your liability carrier far this event? 5 �C �i � ��r L I % i (�U L_� � � �N
Atlach proof of tiabitity i�:sura�ice in the amouxt of One Million Dollars ($1,00O,OOQ00.) All
policies shall name t/:e City of Zephyrhills as an additional insured for fhe even&
C I J� �j I L � .'T► P o L f �-Y � o n1 ►� i L� �4 i �.���"►12f-1 I L LS
l�� I�Po f�� �
I/we agree to obtain and maintain the required liability insurance and to secare all necessary
lacal, state and federal permits and to comply with all terms and conditions applicable to the
conduct of specia].events, as set forth in Ordinance No. 943-06 as amended.
Uwe cerhfy that the information cantained in this application is true snd accurate to the best of
my/our knowledge. As applicant for the event,I/we agree ta release and ho[d harmless the City
of Zephyarhills from liubiUty of any kind for any and all damages arising out of any toss or
iinjury resniting from the conduct of this eveut. This release inclndes a release for any and all
losses or injury arising while conducting an event using City of Zephyrhilis facilities or
property and for any and all losses or injury to persons attending this special event.
I/we certify that individnals wi�[ not be barred fram participation in this event due to race,
creed,color,national orig'rn, sex, age,or physical innpairraent.
� /
BY� ( � �t � v�� Date• � Z- Z� � 2'
` �
Title: � -
Printed Name• � , �� V ( � �����5
S
APPLICATI4N FOR CONSUMPTION OF ALCOHOLIC BEVERAGES.
Events including the consumption of a�coholic beverages must attach proof of liabitity
insurance in the amount of Two Million Doltars ($2,OQO,OOO.QO) naming the City af Zephyrh.tlls
as an additional insured.
No applicant shall be issued more than three perrnits per year, and no permitted event may exceed
two days in rluration.
Please provide a genexal description of how the use of alcohol will be incorporate into the proposed
special event: � _
f � r
�
i
� �
Please attach a diagram,/map to this application depicting specifac clearly identifiable, designated
and secured areas within the event venue where beverage sales and consumption are to occur.
Please attach documentation to this applicativn of appropriate applications for state alcoholic
beverage licensing for this even�
Please provide a descriptian of how security and bevemge Iaw compliance will be provided,
including hours of sale and cansumption during the event:
Please provide a description of the type(s} of beverages(s) and bevexage container(s} to be used in
conjunction with the event:
6
/ ___
I agree to compIy with all terms and conditions applicable to the conduct of special events,
specificalty pertaining to the consumption of alcoholic beverages, as set forth in Ordinance No.
2004-086I, as amended, and further certify that the informatian contained in this application is
trve and correct to the best of my knowledge.
�''� •
B ' . 1 � 3 ! l2
�� Dat�:
Printed Name• ������ ��� .
7
� �
Iyy �,��vG'!�tS ° '�- \.
�- -
� �
�L v ,
r/� �
c.u�
—ti�.---\ �J
��-; cJ
,�
'�- � . '+,�1
, � • "�� �� Y
� � '�i � � � r � j
�J
1 I � � C�
i � �. � �j ,�.
------ -_ ______.._---- _ __________. I _ , o � ? v
�.._�__.......---- .j`` �'s � � � J
_.�,_..,..� _,_..__-_._..__ / O
� ;/
� i� �
� � - �
� �,
�
� �
, !
/
/j � .J�
rV � � V`Jl
,� , � � � �
,�- `� ,n �-
_ � .� ` �
�. .` Q
�o
� � � �
� �
� � �
c�
� � v
,
�. ; � o �i c�'-
� ; � � � �
�— � � �� -- �
�.. �. ,.�� �
� ,�
� � � �
�
k � � �
�,
�
'� Duct Seal Affida�,i'�
,f
P
J
1
Company �,r' ticense#
r
Address ,�'f Permit#
� ,affi�nt,hereby affirm that I a`rri the duly licensed contractor of record for the above
referenced permit,that ail of th,e forgoing information is true and accurate,and that the duct sealing at the above
referenced address has been cpmpleted in accordance with all ap�licable codes and standards.
Contractors Name(pr nted) D+ate
Signature