Fillable Part 1 Retail Stand Location Part 2 Contact

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Part 1 Retail Stand Location Part 2 Contact

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Fireworks Retail Permit updated 5/31/2018 page 1 of 1
Fireworks Retailer Permit Application
Planning & Development Services · 1800 Continental Place · Mount Vernon WA 98273
voice 360-416-1320 · inspections 360-416-1330 · www.skagitcounty.net/firemarshal
Part 1 Retail Stand Location
Property Owner
Parcel #
Site Address
City
Zip
Part 2 Contact Information
Applicant/Person Completing this Form
Name
Organization
Address
City
Zip
Phone
E-mail
UBI #
Retailer
Name
Firm Name
Phone
E-mail
License #
Wholesaler
Firm Name
Phone
Contact Name
Mobile
Part 3 Attachments
Please attach all of the following:
Copy of current Washington State Fireworks Retailer License (obtain from Washington State Fire Marshal at 360-753-0400)
A list of the types of fireworks to be sold, including (1) quantity and (2) size for each type. See RCW 70.77.401 for allowed list.
A site plan that shows all of the following:
stand location
adjacent buildings
streets/roads
parking
distances from all features
Proof of insurance (required by RCW 70.77.381) in the amounts of:
bodily injury liability of at least $50,000 per person, and at least $500,000 per occurrence
property damage liability of at least $50,000 per occurrence
Part 4 Signature
Applicant signature below attests the information above and attached is accurate. Property owner signature conveys consent to use
the property for the described fireworks display.
Applicant
Property Owner
Permit #:
Received by:
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Part 1 Retail Stand Location Part 2 Contact

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Completed 18 July 2020

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