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Home My WebLink About13-14796 ' CITY OF ZEPHYRHILLS 5335-8TH STREET (si3��so-oozo 14796 FIRE SPARKLERS PERMIT Permit Number: 14796 Address: 7422 GALL BLVD Permit Type: FIRE SPARKLERS ZEPHYRHILLS, FL. Class of Work: FIRE-SPARKLERS Township: Range: Book: Proposed Use: COMMERCIAL Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 35-25-21-0010-07200-0011 Improv. Cost: Date Issued: 12/06/2013 Name: K-MART Total Fees: 100.00 Address: 7422 GALL BLVC7 Amount Paid: 100.00 ZEPHYRHILLS, FL. 33542 Date Paid: 12/06/2013 Phone: Work Desc: SPARKLER SALE KMART � � ( i �� 1 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 pertormed in accordance with City Codes and Ordinances. "SPARKLERS" per Section 791.01, Florida Statutes, means a device which emits showers or sparks upon burning,does not contain any explosive compounds,does not detonate or explode, is handheld or ground based,can not propel itself through the air,and contains not more than 100 grams of chemical compound which produces sparks upon burning. ,_.� : , Q�� . � , �� , r; ,� ,.� � �_>-, CONTRACTOR SIGNATURE PERMIT OFFICE PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED ZEPHYRHILLS FIRE RESCUE - 813-780-0041 'fH Result Report p i 12/27/2013 09:03 Serial No. AoEDl�fiiooi4se TC: �90220 Addressee Start Time Tia�e Prints Result Note 97800044 12-27 09:01 �:02:12 009/009 OK TMR7t: rimeerd rx.aP3OnL: P li'ng OF�: a^i inac1s�size 3 ting FME:wFarrame Era e raxx. Note BNDe Do�ble-�XedCOnfidefi 4a1��al�ilet3nC3SIP��iP FaxF�PADR:F P�AddreTx:Fae,TX. RLY: Re ay I-FRX: nternet�Fax Result OK: Communication OK, S-OK: Stop Communication, P4V-OFF: Power Switch OFF, TEL: Rx from TEL, NG: Other Error, Cont: Contin�, No Ans: No Answer, Refuse: Receipt Refused, Busy: Busy, M-Fu11:Memory Full, LOYR:Receiuing len9th Ouer, POUR:Receiuing page Ouer, FIL:File Error, DC:Decode Error, I�N:MDN Response Error, DSN:DSN Response Error. � � CITY OF ZEPHYRHILLS 5335-67H STREET (Bi3j 780-0020 '�4796 FiRE SPARKLERS PERMIT arrn urrsbsr: 4 dr�as: Porm�t Typ�: FIRE 3PARKLERS ZEPHYRHILLS, FL_ Class of Worlc: FIRE-3PARKLERS Townsi�Ep: Ran�s: Booic: Pe-opos�d Use: COMMERCIAL Lot(s): Bloc�e- S�ction: Squar� F��t: SubdlWsfon: CITY OF ZEPHYRHiLLS Ea�. Va1us: Paro�l Numb�r: 35-25-2'l-00'10-07200-00'11 �mprov_Cost: ��t��sswd: '1206/20'13 am�; _ Total FNS: '100.00 Addrrss: 7422 GALL BLVp Amourft Pald: 'f00.00 ZEPHYRHILLS. FL. 33542 �ato Pald: �2/06/20'13 ptio��. o �scc C p!�633.F�pida S4tut�s�a z� C!y to npa a aat usar f�as!�p p�Y r •oosfs r+e prwvantlon and probc.tlon ralsEwd aciiv�tle�wd��s tnsp�Wons pt�r� rrviaw��dmlMStrallw fw�and olhar oo�b rr�ab�d bo lf�a atb�amantlonad. mP ta P ns, S tbr�s and F�c Musi AocornpanY P��. mm�rwem�nt wo w out wr(tben approva the Flrr D�cpar[menYs Flro Marshal or requlr�cl permRs or o inspectlon shell be diargad double permK Me per P°��n� up Tor aommercfal activlty wlthout an approv�ad flnal day a�operntton or a minlmum of 5100.00,whichcrer Is proaL�r_ All worlc shall b� rmed in aoaordanae wilti G Qodas and Ordinanaes. "SPARlQER�" pr�r on 7�1.01� R o a�!a burMnp.doas no!contaln any a�1oNv�oo�n �� nMns a d�v p �r�s bs N�ow�rs or ap� upon bas�d.�an not prop�1�f tl�ro Pounds doa�not daEOnate or a�qs�odM�s tiandh�ld or pround aqh llse a�r�and co��talns net�nerr tl�an 10o prarr�s of'�ha�n�pl oo�npound -- _ wti�cM p�^oduce��aa�iQ uOOn burn�n� � � � T � v3.i- \) .....-�� c �.f c�r�-�'�' CONTRACTOR SIC3NATURE PERMIT OFFICE -' PERMrr EXPIRES IN 30 OAYS WZTHOYT APpROVE�INSPEC7ZpN CALL FOR INSPECTiON -8 MOUR NOTiCE REQUIRE� ZEPHYRHILLS/°IRE RES+CUE- H13-7a0-0p41 a�3-�ao-oo2o City of Zephyrhills Fire Fax-S13-780-0021 Permit Application Date Received ± -Z— Phone Contact for Permit s�� 868 9151 Owner's Name K-Mart#3761 Owner's Phone Number 8��f �82 1957 owner�s address 7422 Gall Bou�evard,Zephyrhilis, FL 33541 Fee Simple Titleholder Name Titleholder Phone Number C� � �� Fee Simple Titleholder Address , , . . , ,. Job Address 7422 Gall Boulevard Lot# � Sub Division Parcel# � Bio-Hazard Waste Storage-ANNUAL � Hazardous Material(Tier II or RQ Facility)ANNUAL � Comm Exhaust Kitchen Hood/Duct Hood Installation � Controlled Burn � LP/Natural Gas-Installation "I � � Emergency Generator<30 kw � LPlNaturai Gas-ANNUAL Sale �� t � Emergency Generator>30 kw � Places of Assembly-ANNUAL X� ` � � I Fire Protection Maintenance-ANNUAL Recreational Burn �y emi �n er Sprinkler � ❑ o ❑ � X❑ Sparklers Inside Retail Sales of State Approved Sparklers Fire Alarm � ❑ ❑ ❑ � � Sprinkler System Installations Hood Cleaning � ❑ ❑ ❑ � � Standpipes(Sprinkler Sys) Hood Suppression � ❑ ❑ ❑ � � Torch Roofing/Tar Kettle � Fire Alarm Installation � Waste Tire Storage ANNUAL � Fire Pumps XX Fire Works-SPARKLERS � Flammable Application-ANNUAL a� Valuation of Project Fuel Tanks Q Other Contractor Company Signature Registered Y/N Fee Current Y/N Address License# ELECTRICIAN Company Signature Registered Y/N Fee Current Y/N Address License# PLUMBER Company Signature Registered Y/N Fee Current Y/N Address License# MECHANICAL Company Signature Registered Y/N Fee Current Y/N Address License# Vendor Company TNT Fireworks Signature Registered Y/N Fee Current Y J N Address 6255 SE 78th Street, Ocala, FL 34474 �icense# Directions Fill out application completely Owner&Contractor sign back of application,notarized(Or,copy of signed contract with owner) If over$2500,a Notice of Commencement is required(Mechanical work over$5000) Supply two(2)sets of drawings with applicable documentation Allow 10-14 days for review after submittal date Parcel#-obtained from Property Tax Notice(http:!/appraiser.pascogov.com) -Site plan at store-placement dictated by Fire Marshals office -State Sparkler Licence attached -Product List attached ,a►co� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `....� 1 vv2oia 10/31/2013 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 certiflcate 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 requlre an endorsement. A statement on this certiflcate does not confer rights to the certiflcate holder in Ifeu of such endorsement(s). PRODUCER Lockton Companies,LLC NTACT 3280 Peachtree Road NE,Suite#250 PHONE A/C No: Atlanta GA 30305 E-MAIL (404)460-3600 ADDRESS: INSURER S AFFORDING COVERAGE NAIC� iNSUReR n:Everest Indemni Insurance Com an 10851 INSURED pmerican Promotional Events,IRC. INSURER B: 1359576 DBA TNT Fireworks,Il]C. INSURER C: ITl 26743 P.O Box 1318 iNSUReR o.Berkshire Hathawa Homestate Ins Co 20044 4511 Helton Drive INSURER E:StBiI'S lus Lines Insurance Com an 13604 Florence AL 35630 INSURER F.�CIl S CC131 Insurance Com an 21199 COVERAGES CERTIFICATE NUMBER: 12080349 REVISION NUMBER: �CXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMELl 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 TypE OF INSURANCE ADD SUBR POLICY EFF POLICY El(P LTR POLICY NUMBER MM/DD MM/DD ��M�TS A 6ENERALLIABILITY N N SI8GL00242-13t 11/1/2013 11/1/2014 DAMAGETO RENTED MMERCIAL GENE BILITY PREMISES(Ea occurrence) $ 3OO OOO CLAIMS-MADE �OCCUR MED EXP M one erson PERSONAI_8 ADV INJURY $ 1�OOO�OOO GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCT,S-COMP/OP AGG POLICY PR� X LOC $ $ AUTOMOBILE LIABIIJTY N N SI8CA00012-131 11/1/2013 11/1/20t4 (Ea accident) $ X ANY AUTO 80DILY INJURY(Per person) 3 ALL OWNED SCHEDULED BODILY INJURY Per accident X HIR DSAUTOS X NON-OWNED PROPERTY DAMAGE $ XX��XXXX AUTOS $ XXXXXXX C X UMBRELLA LIAB X OCCUR N N EXC6023470-01 11/1/2013 11/1/2014 EACH OCGURRENCE $ S OOO OOO EXCES3 LWB CIAIMS-MADE AGGREGATE $ DED RETENTION$ g D WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY N ALW001224(AOS) 11/1/2013 11/1/2014 X TORY LIMIT ER D ANY PROPRIETOR/PARTNER/EXECUTIVE Y�N N�A •See below policies OFFICER/MEMBER EXCLUDED7 � E.L.EACH ACCIDENT $ (Mandetory In NH) E.L.DISEASE-EA EMPLOYE $ 1 �Q�000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E Excess Liability(Starr) N N 1000010240 1]/1/2013 11/1/2014 $5,000,000 xs$5,000,000 p Excess Liability(Arch) UXP0056189-00 11/1/2013 11/1/2014 $10,000,000 xs$10,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Atlach ACORD 101,Addkional Remarka Schedule,if more spacs is rcqulrod) *(G)(CA)Cypress Insurance Co; Workers Compensation:Policy#3 3000629 1 5-1 3 1,Policy Term: 11/1/2013-2014. (H)(OR)Continental Divide Insurance Co; Workers Compenation:Policy#ORW001321,Policy Term:1 I/]/2013-2014 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WRH THE POLICY PROVISIONS. 12080349 AUTHORIZED REPRESENTATIVE American Promotional Events d.b.a.TNT Fireworks 6255 SE 78th Street Ocala FL 34472 �G�� , �EPHYRHlLLS FIRE DEPl�RTl�E[�T 6907 Dairy Road, Zephyrhills, FL 33542 FIRE SERVICE USER FEES Occupancy No.: Plan No.: Contractor: Business Name: Billing Address: Business Address: Business Phone No.: Billing Phone No.: Business Fax No.: Biliing Fax No_: Contact: Contact: PLAN REVIEW FEES INSPECTION FEES PERMIT FEE FALSE ALARM FEE 8 Site Plan N!C Mnual WC Sprinkler �50 1st Alarm N/C Muki-Family/Commeroial .06 sf 1st Re-inspection N/C Standpipes S50 2nd Alarm N/C (Minimum Charge$25.00 2nd Re-inspection a100 Fire Pump $50 3rd Alarm N/C �Plan Revisions DBL 3rd Re-inspection $250 Hoods �50 4th A1arm $1pp 4th Re-Inspection $500 Fire Alarm �50 5th Alam► $15p SPRINKLER SYSTEMS (Business dosed until LP Gas �50 6th Alartn $2pp 0-25 Heads S50 violations corrected) Natural Gas a50 NON COMPLIANCE a150 26 plus Heads $100 SPRINKLER SYSTEMS Fuel T � STANDPIPE SYSTEM Hydro Undergrounds $45 Spa�iclers � Per Riser $50 Hydrostatic Test $65 Pe s 5500 FIRE PUMP Acceptance Test $45 per system Camp Fire 325 � Per Pump a100 Hydrant Flow $75 Controlled Bum 5100 FIRE ALARM SYSTEM Hood/Duct $50 e0-25 Devices $50 FIRE ALARM SYSTEM Place of Assembly $50 au,uai 26 plus Devices $100 System Acceptance $50 Fire Protection S25 SUPPRESSION SYSTEMS Recall Acceptance �50 Flammabie Applicatio� S50 amuai Wet $50 OTHER Waste Tire Storage a50 nnm,a� Dry a50 Fire Wa1USmoke Wall �15 perwau Generator<KW b100 CO2 $50 LP Gas $25 per tank Generatof>30 KW 150 Other a50 Natural Gas �25 Per system Bio-Hazard Waste 5100 �nnuai KITCHEN EXHAUST Fumigation Tenting $50 � Hood/Duds $50 Tent 10k10'or greater $15 Per te�t Torch PodApplied $50 OTHER Fire Pump $45 Haz.Materiafs a100 �nnua� 8 LP InstallaUon per tank �50 Fire Suppression �30 Fuel Tank Installation a50 System Acceptance (Per Tank) a50 Exhaust Hood/Duct S30 �Nawral Gas Inscallation �50 Re-inspection DBL (Per System) (other than annual) �Spray Booth �50 � Inspection scheduled DBL 8 and cancelled less than 24 hours Construction Insp. WC Emergency Vehicie A� $50 FALSE ALARM -- --PL�WS-Tt��y4L-}- -�- ----iNSi�ECfiION�fjTAL�- PfftMl��'��y4i-�-- ----�flTi1t�— GRAND TOTAL Comments: Date: � ��-' '�i 1 Inspector: �;,�.�2.�� nin MAY, 9. 20i3 12. 32PNi TNZ �4AIN OFFICE NG, 3454 '? Z " .,_, TNl� F[REWORKS Sit{e Pfan Workah�et �1DDRES3 � � �16/ '� 2 Z _ ��r/ � L ✓� srot� �'A� FL zip 3 � PHON� � �3 �j�� NAME 1 I.00ATtON# C �(e/ � /G�C..S' T Y P E 0�E 1/E N T: n•�tn sel o orid ts ao H Y�V 4� t� _xa � � � � � --�-----��..�. �y��31,nt"1`TF;� PI_ANftS} � 'E T�EN REYi�W3ir `!�} f� i-�YR LI��FIF:E ARSHAL S OFFICE � Jat�: _ N � � �• � ^..,�;.z;�,.,,,. ____._�`�',-�_s , . � � Z °_ —I��-- - - x x K `'r^ � 1C K �c .� SOIRy �pFCtAL r k 18 ro �-.-.. StGkATURE�� l+�,l�r,d.,••-�- sror,�at��eR�n��,�,� ��TE S-'9— 13 Aco� CERTIFICATE OF LIABILIT DATE(MM/DD/YWY) Y INSURANCE11,,,20,4 10/31/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY 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(ies)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 Lockton Companies,LLC NAMEACT 3280 Peachtree Road NE,Suite#250 PHONE Fnx Atlanta GA 30305 �U� ac No: E-MAIL (404)460-3600 ADDRESS: INSURER S AFFORDING COVERAGE NAIC# INSURER A Everest Indemni Insurance Com an 10851 INSURED American Promotional Events,IriC. INSURER B. 1359629 DBA TNT Fireworks,II1C. INSURER C. P O BOX I3 I g INSURER D. 451 1 Helton Drive Florence AL 35630 INSURER E. INSURER F. COVERAGES CERTIFICATE NUMBER: 12067058 REVISION NUMBER: XXXXXXX 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 PO�ICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DDIriYY MM/DDlYYYY LIMITS A GENERAL LIABILITY Y N SI8GL00242-131 1 U1/2013 1 UI/2014 DAMAGETO RENTED MMERCIAL GENE BILITY PREMISES(Ea occurrence) $ 3OO OOO CLAIMS-MADE �OCCUR MED EXP Am one erson PERSONAL&ADV INJURY S 1�OOO,OOO GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG POLICY PR� LOC $ AUTOMOBILE LIABILITY NOT APPLICABLE � (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ AUTOS NED AUTOSULED BODILY INJURY Per accident $ XXXXXXX HIRED AUTOS AON-OSWNED PROPERTY DAMAGE $ XXXXXXX $ XXXXXX�{ UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS�IAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION NOT APPLICABLE W TA'U- H- AND EMPLOYERS'LIABILITY Y�N TORY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH AC�'IDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ X�{�}{}{X If yas,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (Attach ACORD 701,Additional Remarks Schedule,if more space is required) City of Zephyrhills and Certificate holder is an additional insured on the General Liability as required by written contract subject to policy tc;rms,conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12067058 AUTHORIZED REPRESENTATIVE K-Mart #3761 7422 GALL BOULEVARD ZEPHYRHILLS FL 33541 --�--1 � � - �� ,� � , ACORD 25(2010/05) The ACORD name and logo are regtstered marks of ACORD OO 9�H- 'I O CORD CORP TION.All rights reserved ►.e�cr v iew Yage 1 of 1 Jei(Ataater Gds S(nw CHIEF FINAlYC1Ai,OFFTCER BUREAU CHIEF Julius HaG�s Keit4 McCarth DMSION DIRECTOR Y SAFE7'Y PROGRAM�YlANiAGER FLORIllA D�LFA�IVT pF FINANCIAL SERVICES DIVISION OF STATE FIRE MARSHAL 200 East Gaines Street -T�Ilshassa,Florida 32399-0342 Tel.550-413-3b44 Fex.850-4I0-2467 CER1'�FICATE OF REGbSTRATION � RETAILER LQCATION PERMIT OFFICIAL COPY THIS CERTIFIES�fiAT: K-Mart/Sears Holdings 6255 SE?8th Street Ocala F134�72 Has registered pursuant to tt�e provisions of Ftorida Statues to engage in the business of selling sparklers at the following fixed piace of business: K-Mart#3761 7422 Gail Blvd Zephyrhills FL 33541 Pasco Issue Date: 03/21/2013 Type: 07 Class: 66 County: Marion LicenselPermit#: 211018-0033-2011 Expiration Date: 01/31/2014 ' � . . , �` . Chief Financial OPflcer hrips://www.citizenserve.com/Admin/PermitController?Action�heckPrintingConditions... 3/21/2013 �53-01720907 - REPRINT - TNT FIREWORKS PACK LIST - REPRINZ' - 21362 Order #: 1720907-53-00002 Chain Store Sales-FL Chains Order Date: 10/16/13 Terms : Net 30 Days CUST PO: SLSMN: Chain Stores - East Sold To: 1420037 Ship To: 976089 - KMT3761. KMART STORES - COMPANY 0002 KMART 3761 3333 BEVERLY ROAD, C4-250A 7422 GALL BOULEti'ARD HOFFMAN ESTATES, IL 60179 ZEPHYRHILLS, FL 33541 Desc/Case Packing Item Quantity Sel.ling Suggested CP # Ordered Uni.ts Sell Price ------------------------- -------------------------------------�---------------- -- *************************** Counter Cases ****��****************** DSP 50 SS SM W/GBFSNPSPK J13T 672485 1 CS 1 EA 1725 . 6200 1/1 Containing: BOOMIN SALUTE SS J10 COM 102073 4 EA 4 EA 59 . 99 6/1 2481231 SHOW OF FREEDOM USA SS J09 101831A 6 EA 6 EA 39 . 99 10/1 2481234 FREEDOM RINGS SS USA J09 101832A 10 EA ]_0 EA 24 . 99 16/1 2459780 PARTY PAK SS-USA J09 101933 6 EA 6 EA 15 . 99 16/1 2459772 STARS AND STRIPES COM SS J 101833 12 EA ]_2 EA 9 . 99 24/1 2481229 SUPER VALUE PACK REV J09 200722 6 EA 6 EA 10 . 00 12/3 2491296 CAL ROCKET FOUNTAIN 3-PK 200967 30 BG :SO BG 5 . 00 2/30/3 27736028450 GROUND BLOOM FLOWER 20 CT 290157 20 EA 2.0 EA 5 . 00 4/20/20 27736030255 STRIKER J10 200862 8 EA 8 EA 5 . 00 24/1 3559589 MINI CALIFORNIA RKT 3PK J 200849A 24 EA <?4 EA 2 . 00 6/24/3 27736025602 DINOSAURS FTN 3 PK SM PDQ 200816A 16 EA =L6 EA 2 . 00 4/16/3 2480674 2 PAK SNAP SM PDQ 931247 J 320516H 82 EA £32 EA 1 . 00 4/41/2/50 2343126 #8 SPRKLRS ASST BOX W/PDQ 380236A 72 EA '72 EA 2 . 00 4/24/6/5 27736022755 CRAZY EYE BALLS W/ PDQ J13 290067B 42 EA 42 EA 1 . 00 8/42/3 27736013210 DOUBLE PAK MORNING GLORY J 380276 54 EA 54 EA 1 . 00 4/54/8 27736029426 SIGN - NO SMOKING 730099E 1 EA 1 EA 0 . 00 1/1 SHORT STACK J13 200924B 28 EA 28 EA 1 . 00 8/28 27736028054 Page No 1 - REPRINT - TNT FIREWORKS PACK LIST - REPRINT - Order #: 1720907-S3-00002 Desc/Case Packing Item Quantity Selling Suggested CP # Ordered Units Sell Price --- - ---------------- ------------------------------------------------------------ Case Totals : 1 CS Total Pallets : PL Total Repack Cases : CS DECLARATION OF COMPLIANCE American Promotional Events, Inc . , dba TNT Fireworks, certifies that all consumer fireworks identified on this invoice have been teste� by the American Fireworks Standards Laboratory and found to conform with all applicable regulations, standards and bans enforced by the U. �� . Consumer Product Safety Commission. Testing and certification for these items complies with rules, standards and bans applicable to consumer fireworks : Performance Standards 16 CFR 1500 . 17 (a) (9) 16 CFR 1500 . 17 (a) (1.1) 16 CFR 1500 . 17 (a) (12) 16 CFR 1507 Powder Content Bans 16 CFR 1500 . 17 (a) (3) 16 CFR 1500 . 17 (a) (8) 16 CFR 1500 . 85 (a) (2) Cautionary Labeling 16 CFR 1500 . 14 (b) (7) 16 CFR 1500 . 83 (a) (27) Contact information for laboratory that performed conformity t:esting. American Fireworks Standards Laboratory (AFSL) 7316 Wisconsin Avenue, Suite 214 Bethesda, MD 20814 301-907-9115 afslhq@afsl .org CONTACT INFORMATION FOR INDIVIDUAL MAINTAINING RECORDS ON WHIC.H DECLARATION IS BASED: NAME: Kathie Pendergrass ADDRESS : 4511 Helton Drive Florence, Alabama 35630 TELEPHONE: 256-764-6131 FAX: 256-767-7200 E-MAIL: pendergrassk@tntfireworks . com. www. tntfireworks . com Page No 2