HomeMy WebLinkAbout2800 LOMA LINDA DRIVE (7)INSPECTIONS
FIRE SAFETY INSPECTIONS)
HAZARDOUS CONDITIONS PERMIT APPLICATION
PERMIT: # 1 Z -1 d0W `-k'0
I
jAFJR S F t E D
BE
1. TM T
L
BAKERSFIELD FIRE DEPT.
PREVENTION SERVICES
1501 Truxtun Ave.
Bakersfield, CA 93301
Tel: (661) 326 -3979
Fax: (661) 852 -2171
Page 1 of 1
In conformity with provisions ofpertinent ordinances, codes and/or regulations, application is made by:
a.• -C V • U-f- c-Z SSCo S(,s - . b. • 93,2
Name of Company Address City, State, Zip
Contact Name Phone No. Cell No.
To display, store, install, use, operate, sell or handle materials orprocesses involving or creating
conditions deemed hazardous to life or property as follows:
3(n Z — 0 Cf 5--v
X
Authorized Representative of
Company Requesting Inspection
A PERMIT WAS Issued on ld.Z / /'L By: X.
t '
E3 Denied Date Inspecting Officer /Fire Marshal
FO 2039 White Copy to File Card Copy to Permittee for Display
TENTS
ALL OTHER PERMITS See attachments
LOCATION OF INSTALLATION:
6`00
EVENT DATE & PURPOSE:
SET UP: TAKE DOWN: READY FOR INSPECTION:
AFTER HOURS / WEEKENDS
12—
NUMBER OF TENTS: SIZE: NUMBER OF TENTS: SIZE:
PYRO TECH NAME: PYRO TECH PHONE #: PYRO LIC #/
Pe L l.J o q /O —C'Z
3(n Z — 0 Cf 5--v
X
Authorized Representative of
Company Requesting Inspection
A PERMIT WAS Issued on ld.Z / /'L By: X.
t '
E3 Denied Date Inspecting Officer /Fire Marshal
FO 2039 White Copy to File Card Copy to Permittee for Display
INSPECTIONS
FIRE SAFETY INSPECTIONS)
HAZARDOUS CONDITIONS PERMIT APPLICATION
PERMIT: # 12 – I ocyna 4.51
JARTMR 3 F I E D
FIRE
T
BAKERSFIELD FIRE DEPT.
PREVENTION SERVICES
1501 Truxtun Ave.
Bakersfield, CA 93301
Tel: (661) 326 -3979
Fax: (661) 852 -2171
Page 1 of 1
In conformity with provisions ofpertinent ordinances, codes and/or regulations, application is made by:
S- ti 5C t i F g`T K , 04-. 'j 3 ;/ :5
Name of Company Address City, State, Zip
G 31 — Z z 7 z-.. <:--5 / — 73 G ';-
Contact Name Phone No. Cell No.
To display, store, install, use, operate, sell or handle materials or processes involving or creating
conditions deemed hazardous to life orproperty as follows:
A PERMIT WAS Issued on l0 /'//7_ By:
0 Denied Date
X
Authorized Representative of
Company Requesting Inspection
Inspecting fflcer /Fire Marshal
FD 2039 White Copy to File Card Copy to Permittee for Display
TENTS
ALL OTHER PERMITS See attachments
LOCATION OF INSTALLATION:
EVENT DATE & PURPOSE:
SET UP: TAKE DOWN: READY FOR INSPECTION:
AFTER HOURS I WEEKENDS
NUMBER OF TENTS: SIZE: NUMBER OF TENTS: SIZE:
i 3o )c C" Z) 4) )cz0
PYRO TECH NAME: PYRO TECH PHONE #: PYRO LIC #/
A PERMIT WAS Issued on l0 /'//7_ By:
0 Denied Date
X
Authorized Representative of
Company Requesting Inspection
Inspecting fflcer /Fire Marshal
FD 2039 White Copy to File Card Copy to Permittee for Display
BILLING & PERMIT STATEMENT BAKERSFIELD FIRE DEPARTMENT
B Iir E R 5 P it o' ,, Prevention Services
PERMIT # p p Re !!!`. 1501 Truxtun Avenue, 1St FLR
DOAR TWO f Bakersfield, CA 93301
r.:!a aattr PhnnP: 661 - 'I26- '4979 • Fax: 661 -S52 -2171
LOCATION OF PROJECT 2131 Elm Street PROPERTY OWNER
STARTING DATE 10/04/12 COMPLETION DATE 10/08/12 NAME Same
PROJECT NAMEC.A.S.A Of Kern County ADDRESS 2131 Elm Street PHONE #661-631-2272
PRO)ECTADDRESS 124 Columbus Ave CITY BAKERSFIELD STATE CA ZIP CODE 93301
CONTRACTOR NAME
CONTRACTOR INFORMATION
CA LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE #
CONTRACTOR COMPANY NAME FAX #
ADDRESS CITY ZIP CODE
All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK.
Alarm - New & Modification (minimum charge) $280
Over 10,000 sq ft $0 .028 x sq ft
15608
WALKER -LEWIS RENTS C CIVS _ P.O. Box 10592 4600 caff,BrNgIYS Bakenein cA Sa oeBakersfield, CA 93389 90- 3414 -1222
661- 831 -7368
5
NINETY -SIX AND 00 / 100 DOLLARS
DATE CHECK NO. AMOUNT
a
i
10/02/12 * * * * * * ** I THE
CITY OF BAKERSFIELD $96.003DER
a
AUTHO
III01S60811' 1:1222341491.0 021033324118
NOTE: $96 /hr for each type of test /per site even if
scheduled at the same time TT
0 Oil well (Installation, Inspection, or re- inspection) X 96 /hr 82
r Tent # 96 /tent 84
After -hours inspection fee 121 /hr (2 hrs minimum) =$242
Pyrotechnic (1 permit per event, plus an inspection fee of
96 /hr during business hours) PY
NOTE: After hours Pyrotechnic event inspection is @ $121 /hr
96 /hr + (5 hrs min standby fee /insp) =$576
5 hrs min standby fee ins = 605
84
Re- inspection /Follow -up Inspection 96 /hr 84
Portable LPG (Propane): # of Cages? _ 96 /hr 84
Explosive Storage 266 84
Copying & File Research (File Research fee $50 /hr) 0.25 /page 84
Miscellaneous 84
PERMITS & ENTERTAINMENT
TENT & CANOPY PERMITS
APPLICATION FORM,
PROCEDURES, & INSTRUCTIONS
I3 ^ts D
P/RQ
OVA RrN f
BAKERSFIELD FIRE DEPT.
Prevention Services
1501 Truxtun Ave., 1St Floor
Bakersfield, CA 93301
Tel.: (661) 326 -3979
Fax: (661) 852 -2171
Page 1 of 1
PLOT PLAN MUST PROVIDE THE FOLLOWING INFORMATION
Any temporary membrane having an area in excess of 200 sq. ft. and /or Canopy /s (top only) in excess of 400 sq. ft. requires a permit (UFC §2.101)
Application for a tent permit must be made at least 24 hours prior to the Fire Safety Inspection and the fire safety Inspection must be completed
and approved prior to operation.
Please Note: If tents are not ready for inspection at the time stated, there may be a re- inspection fee charged or an after -hours inspection fee charged.
1. Location of tent or tents in respect to the following,
a. Property Lines
b. Building Structures
C. Vehicle Parking
d. Liquefied Petroleum Gas Containers
e. Flammable and Combustible Liquids
NOTE: Tents and canopies SHALL not be located within (20) feet of property lines, buildings,
temporary membrane structures, other tents and canopies, parked vehicles or internal
combustion engines.
2. Location of NO SMOKING signs, FIRE EXTINGUISHERS.
NOTE: One Class 2 -A fire extinguisher shall be provided in every tent having a floor area between 500 sq. ft.
and 1000 sq. ft. plus one 2 -A fire extinguisher in each auxiliary adjacent tent.
One additional extinguisher shall be provided for each 2000 square feet or fraction thereof.
3. Exits: No point in tent to be more than 100 ft. from an exit.
4. Seating plan: With minimum isle measurements provided. (If applicable)
NOTE: No flammable vegetation within (50) feet of any tent. Hay, straw, trash, or other flammable material
shall be stored more than (50) feet from any tent.
NOTE: If tent or canopy does not meet the above requirements, a permit will not be issued and a
re- inSDection fee will be reauired.
APPLICATION PERMIT: # I
NAME OF COMPANY I PERSON REQUESTING TENT APPLICATION Walker -Lewis Rents PHONE 661- 831 -7368
ADDRESS 4501 Ride St. ITY Bakersfield TATE CA zip 93313
NAME OF COMPANY OR LOCATION OF INSTALLATION PHONE NUMBER 661 -631-
2272
ADDRESS 2131 Elm Street ITY Bakersfield TATE CA IP 93301
NUMBER OF TENTS TO BE INSTALLED: —2— ENT SIZE: (1 ) 30 FT. X
0 > 10 FT. x
FT. X
60 FT.
20 FT.
FT.
ET UP DATE TENT(s) TO BE INSTALLED: 10/04/12 TAKE DOWN DATE TENT(s) TO BE REMOVED: 10108/12
ENT READY FOR INSPECTION ON (Date): 10/05/12 APPROXIMATE TIME: 3:00 pm
AFTER HOURS /WEEKENDS
ENT READY FOR INSPECTION ON (Date): FTER HOURS /WEEKENDS (Date):
OCCUPANCY USE OF TENT(s) [explain]:
EVENT DATE(s): 10/06/12
RE THERE TO BE INSIDE DECORATIONS? YES &ONO
NOTE_ State Fire Marshal Certificates of Flame Resistance for all tent fabrics and all interior decorative fabrics shall be provided prior to i suing of permits.
RE LIGHTS BEING INSTALLED: 7 YES NO HEATING: YES V NO COOKING APPLIANCES:
NOTE_ Explain type of equipment to be used for heating and cooking appliances.
YES NO
FD 2063 (Rev. 09/05)
BILLING & PERMIT STATEMENT
PERMIT # FIRE
AR1M T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1s' FLR
Bakersfield, CA 93301
Phone: 661- 326 -3979 • Fax: 661- 852 -2171
LOCATION OF PROJECT 2131 Elm Street PROPERTY OWNER
STARTING DATE 1004/12 COMPLETION DATE 10/08/12 NAME Same
PROJECT NAME C.A.S.A Of Kern County ADDRESS 2131 Elm Street PHONE # 661- 631 -2272
PROJECT ADDRESS 124 Columbus Ave cm BAKERSFIELD STATE CA ZIPCODE93301
CONTRACTOR INFORMATION
CONTRACTOR NAME CA LICENSE # TYPE OF LICENSE EXPIRATION DATE PHONE #
CONTRACTOR COMPANY NAME FAX #
ADDRESS CITY ZIP CODE
All permits must be reviewed, stamped, and approved PRIOR TO BEGINNING WORK.
Alarm - New & Modification (minimum charge) $280 •
Over 10,000 sq ft 0 .028 x sq ft
Sprinkler - New & Modification (minimum charge) 280
Over 10,000 sq ft 0 .028 x sq ft
Minor Sprinkler Modification ( <10 heads) 96 (inspection only) 84
Commercial Hood (New & Modification) 470
Additional hood 58
Spray Booth (New & Modification) 470
98
Aboveground Storage Tank (1 inspection per installation) AST 180 /tank 82
Additional Tank ATI 96 /tank 82
Aboveground Storage Tank (Removal, Mod,or Inspect'n) ATR 109 /tank 82
Underground Storage Tank (Installation /Inspection) NI 878 /tank 82
Underground Storage Tank (Modification) MOD 878 /site 82
Underground Storage Tank (Minor Modification) MTM 167 /site 82
Underground Storage Tank (Removal) TR 573 /tank 84
Mandated Leak Detection (test) /Fuel Mont Cert/SB989
NOTE: $96 /hr for each type of test /per site even if
cheduled at the same time TT
96 /hr (2 hrs minimum) =$192 84
Oil well (Installation, Inspection, or re- inspection) X 96 /hr 82
Tent # 96 /tent 84
After -hours inspection fee 121 /hr (2 hrs minimum) =$242
Pyrotechnic (1 permit per event, plus an inspection fee of
96 /hr during business hours) PY
NOTE: After hours Pyrotechnic event inspection is @ $121 /hr
96 /hr + (5 hrs min standby fee /insp) =$576
5 hrs min standby fee ins = 605
84
Re-inspection /Follow -up Inspection 96 /hr 84
Portable LPG (Propane): # of Cages? _ 96 /hr 84
Explosive Storage 266 84
Copying & File Research (File Research fee $50 /hr) 0.25 /page 84
Miscellaneous 84
PERMITS & ENTERTAINMENT
TENT & CANOPY PERMITS
PROCEDURES, & INSTRUCTIONS
FOR APPLICATION FORM
F D
IR ! JrIR
f
BAKERSFIELD FIRE DEPT.
Prevention Services
1501 Truxtun Ave., 1st Floor
Bakersfield, CA 93301
Tel.: (661) 326 -3979
Fax: (661) 852 -2171
Page 1 of 3
Application for a tent permit must be made at least 24 hours prior to the Fire Safety Inspection
and the fire safety inspection must be completed and approved prior to operation.
Please Note: If tents are not ready for inspection at the time stated, there may be a re- inspection fee
charged or an after -hours inspection fee charged.
TENT: A temporary structure, the covering of which is made of pliable material that achieves its support by
mechanical means such as beams, columns, poles, or arches, or by rope or cables, or both. (NFPA 102:2.2)
CANOPY: A temporary structure, enclosure or shelter constructed of fabric or pliable materials supported by any
manner, except by air or the contents it protects, and is open without sidewalls or drops on 75% or more of the
perimeter. (CFC 3202.2)
TEMPORARY MEMBRANE STRUCTURE. A building or portion of a building incorporating an air - inflated, air -
supported, tensioned - membrane structure; a membrane roof; or a membrane - covered ridge frame to protect habitable
or usable space that is in place for a period of 180 consecutive calendar days or less. (NFPA 102:2.2)
PERMIT:
A permit shall be obtained from the Bakersfield Fire Department Fire Prevention Services to erect or
operate an air - supported temporary membrane structure or tent having an area in excess of 200 sq. ft.
or canopy /(s) in excess of 400 sq. ft. (CFC 105.7 -t. 1)
Tents, Canopies, or Membranes shall be permitted only on a temporary basis not to exceed 180
days In a 12 month period. (NFPA 102: 8 -1; CFC 3204)
LOCATION OF TENTS, CANOPIES OR TEMPORARY MEMBRANES:
Tents, Canopies, or Membranes shall not be located within (20) feet of property lines, buildings, other
Tents, Canopies, or Membranes, parked vehicles, or internal combustion engines. (NFPA 102: 8 -5.3;
CFC 3205.2)
Tents, Canopies, or Membranes shall not be located within (50) feet of flammable and combustible
liquids storage or vegetation. (CFC 3217.2)
Flammable vegetation may be present If treated with approved fire - resistive treatments.
FD 2063a (Rev. 09/05)
PERMITS & ENTERTAINMENT
TENT & CANOPY PERMITS
PROCEDURES, & INSTRUCTIONS
FOR APPLICATION FORM
FLAME RESISTANCE:
Sidewalls, drops, and tops of Temporary Membrane Structures, Tents, and Canopies shall be
composed of flame- resistant material. (CFC 3207)
The Bakersfield Fire Department requires a certificate or other evidence of approved by a laboratory of
recognized standing that the tent fabric materials has the required flame resistance (State of California
Fire Marshal's Seal). (NFPA 102: 8 -4; CFC 3207)
Tents, Canopies, or Membranes shall have a permanently affixed label with the following information:
CFC 3207)
Identification of size and fabric or material type.
The date they were last treated with an approved flame retardant.
The trade name and type of flame retardant utilized in the treatment.
The name of the person and firm that applied the flame retardant.
No hay, straw, shavings, or other combustible material shall be permitted within any structure used as
an assembly unless it has been treated with an approved fire retardant. (NFPA 102: 9 -2.3)
FIRE EXTINGUISHERS:
Fire extinguishers shall be provided in every Tent, Canopy, or Membrane structure at: (NFPA 102:9-
3.3)
Under 500 sq. ft. of floor area; One (1) 2 -A; 10 -BC
500 — 1,000 sq. ft. of floor area; Two (2) 2 -A; 10 -BC
Each additional 1,000 sq. ft. of floor area; One (1) additional 2 -A; 10 -BC
NO SMOKING SIGNS:
Smoking shall NOT be permitted in Tents, Canopies, or Membrane Structures or in adjacent areas
where hay, straw, sawdust or other combustible materials are used or stored. (NFPA 102: 9 -2.4; CFC
3215.1)
FD 2063a (Rev. 09/05)
BAKERSFIELD FIRE DEPT.
A,_ Prevention Services
B B R S P I D 1501 Truxtun Ave., 1 s Floor
AFRONN T Bakersfield, CA 93301
Tel.: (661) 326 -3979
Fax: (661) 852 -2171
Page 2 of 3
Sidewalls, drops, and tops of Temporary Membrane Structures, Tents, and Canopies shall be
composed of flame- resistant material. (CFC 3207)
The Bakersfield Fire Department requires a certificate or other evidence of approved by a laboratory of
recognized standing that the tent fabric materials has the required flame resistance (State of California
Fire Marshal's Seal). (NFPA 102: 8 -4; CFC 3207)
Tents, Canopies, or Membranes shall have a permanently affixed label with the following information:
CFC 3207)
Identification of size and fabric or material type.
The date they were last treated with an approved flame retardant.
The trade name and type of flame retardant utilized in the treatment.
The name of the person and firm that applied the flame retardant.
No hay, straw, shavings, or other combustible material shall be permitted within any structure used as
an assembly unless it has been treated with an approved fire retardant. (NFPA 102: 9 -2.3)
FIRE EXTINGUISHERS:
Fire extinguishers shall be provided in every Tent, Canopy, or Membrane structure at: (NFPA 102:9-
3.3)
Under 500 sq. ft. of floor area; One (1) 2 -A; 10 -BC
500 — 1,000 sq. ft. of floor area; Two (2) 2 -A; 10 -BC
Each additional 1,000 sq. ft. of floor area; One (1) additional 2 -A; 10 -BC
NO SMOKING SIGNS:
Smoking shall NOT be permitted in Tents, Canopies, or Membrane Structures or in adjacent areas
where hay, straw, sawdust or other combustible materials are used or stored. (NFPA 102: 9 -2.4; CFC
3215.1)
FD 2063a (Rev. 09/05)
BAKERSFIELD FIRE DEPT.
PERMITS & ENTERTAINMENT Prevention Services
TENT & CANOPY PERMITS B
N
B x a P , n 1501 Truxtun Ave., 1St Floor
IIRQ Bakersfield, CA 93301
PROCEDURES, & INSTRUCTIONS; , ' Tel.: (661) 326 -3979
FOR APPLICATION FORM Fax: (661) 852 -2171
Page 3 of 3
SEATING ARRANGEMENTS
Spacing:
When seating in rows that have 14 or less seats, the minimum clear width between rows shall
not be less than 12 inches.
If the seating exceeds 100 total seats, width between will increase by .3 inches for every seat
beyond 14, not to exceed 22 inches. (CFC 2501.10.1)
Bonding:
Loose seats, folding chairs in excess of 300 and not fixed to the floor, shall be bonded
together in groups of three or more. (2501.10.2)
Exit Signs:
Exit signs shall be required when necessary to clearly indicate the direction of egress when
the exit serves an occupant load of 50 or more. (CFC 3214.1)
COOKING AND HEATING:
Tents where cooking is performed shall be separated from other Tents, Canopies, or Membrane
structures by a minimum of 20 feet. (CFC 3216.3.2)
Electrical heating equipment shall not be located within 20 feet of an exit. (CFC 3216.3, 1)
Electrical systems and equipment shall be isolated from public by proper elevation or guarding, and all
electrical fuses and switches shall be enclosed in approved enclosures. Cables on the ground in
areas traversed by the public shall be placed in trenches or protected by approved covers. (NFPA
102: 10 -1.3)
No fuel fired heaters shall be permitted within any tent, canopy, or membrane structure. (NFPA 102:
10- 2.1.2)
FLAMMABLE AND COMBUSTIBLE LIQUIDS:
Flammable and combustible liquids shall be stored outside in an approved manner not less than
50 sq. ft. from any Tent, Canopy, or Membrane structure. (CFC 3217.2)
Refueling shall be performed in an approved location not less than 20 ft. from any Tent, Canopy, or
Membrane structure. (CFC 3217.3)
Generators and other combustible power sources shall be separated from Tent, Canopy or Membrane
structure by a minimum of 20 ft. and isolated from contact with the public. (CFC 3219)
FD 2063a (Rev. 09/05)
Eerttf irate of ifla ice '.e '5t ,5tante
REGISTERED ISSUED BY: Date treated w
APPLICATION AZTEC TENTS
maruwfactured
P.'
CONCERN No. 490 ALASKA AVENUE 0312006TORRANCE, CA 90503
CAL COMB F- 419.01 (310)328-5060
This is to certify that the materials described below hereof have been flame retardant treated (or are inher-
ently nonflammable).
FOR WALKER LEWIS RENTS ADDRESS 4501 RIDE STREET
crrr BAKERSFIELD STATE CA, 93313
Certification is hereby made that: (check "a" or "b ")
a) The articles described below this certificate have been treated with a flame retardant chemical approved
and registered by the State Fire Marshal and that the application of said chemical was done in confor-
mance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal.
Name of chemical used ............. ............................... Chem. Reg. No.........................
Meathodof application ................................................................. ...............................
b) The articles described below hereof are made from a flame - resistant fabric or material registered and
approved by the State Fire Marshal for such use; Fabric has been tested and passes NFPA701 -96.
Trade name of flame - resistant fabric or material used Laminated Fabric . Reg. No...... F V.Rt
The Flame Retardant Process Used WILL MOT •... Be Removed by Washing
win or will riot).
David Bradley Chuck Miller - President
Name orAppkator or Production Superintendent Twe
30'x60'
Tent
Cabana
a Pit
0
am ® E
40
9 Ras
ao
0
gm
Pool House
Walker —Lewis Rents
4501 Ride Street
Bakersfield, CA, 93313
661 - 831 -7368 Office
Drawn by: Mark
IoX2o
Food PrepW/ Sldewall
rFM
House
ao
Event: CASA Shoe Party
Date of Event:
Location: Carter Home
i5
AMITS & ENTERTAINMENT
ROTECFiNICS
AUBLIC FIREWORKS DISPLAY (Indoor /Outdoor)
ATTACHMENT FORM
Please print legibly.
1; 6.H ti F 1- I_ U
FIRE ; #
ARTM T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 - 326 -3979 • Fax: 661- 852 -2171
Page 1 of 1
APPLICANTS NAME/ • PHONE NO.:
ADDRESS: // / /, P/1 l
SPONSORI RGANIZAIION: L
v l . PHO O 3J te
FAX O:
7
ADDRESS: t F— +%hov A Jt' rx'
TI E O IS L
LOCATION OF DISPLAY: DATE:
From.m, to P.M.
applicant must attach 2 diagrams showing the area and arrangements.)
PERSONS WHO WILL ACTUALLY DISCHARGE THE FIREWORKS AND ARRANGEMENTS (At least two names)
NAME:
r
ADDRESS: PHONE NO.: CA — PYRO LIC #
NAME:
s%
ADDRESS:
S' j2- C1rc..`r r i..t l
PHONE NO.:
G6 37b.. -tic-
CA — PYRO LIC #
c'A-_; 8 -4- t`:, y
NAME: ADDRESS: PHONE NO.: CA — PYRO LIC #
Kind of Fireworks to be used Add attachment if necessary) ry) %• Size of aerial bursts (Add attachment if necessary) 3
California Public Display License Numbe ; C>%L/ Mail Permit to:
Appf t or Firmr Nayynnee:
S
gnature Applicant
1AA-1— — — — —
j'hon
cy43— ,r 1 % J
Date:
1:Z
DO NOT WR TL BELOWTHIS LINE
Remarks and Special Conditions:
Fee: ( Approved (Inspector: (Date
Denied
IRVING L PERRY 2908
562 CENTRAL AVE 80- 1808/493
SHAFTER, CA 93263 -2122 BM ICH2214
7
Date
c f
Pay to the !' _
L '+_ , " $ COrderof -
CYJ
L s^z / -' Dollars ,.
NQ
Lifes le°
0 ~ First National Bank *
For r !b'>• `— ,.J.r',..4 fw
11:04 3 3 11309 24 30111909, 29013 / /
10/04/2012 12:47 6617462844 ZAMBELLI WEST PAGE 01/01
Zambelli
F I R E W O R K S
Fireworks Display
Permit Application
PO Box 986
Shafter, CA 93263
Office 661 746 -2842
fax 661 746 -2844
boomClightspeed.net
Graces Memorial High School
Bakersfield, CJA.
October 12, 2012
Bakersfield Fire Department
Fire Station #1
Attn: David Weirather / Fire Prevention
2101 "H" Street
Bakersfield, CA 93301
661 852 -2171 Fax
661326-3979 office
CONTENTS
Cover Page
Permit Application
Insurance Certificate
Workers Compensation. Insurance
CA Pre- Display
Product List
MaterialS afetyData, Sheet
Transportation Authorization
Califomia Public Display License
Technician ID
Site Plan
This is a 2nd attempt to fire the show
that was scheduled for the Garcis
Playoffs in 2011.
This will be fired on October 12, 2012
for the Annual Homecoming Game
Assuming the permit fee is still $505
the full permitting package will be
delivered to you on Friday October
5, 2012.
PO Box 986
Shafter, 93263Zambellioffice661C7462842
F I R E W O R K S fax 661 746 -2844
boom @lightspeed.net
Fireworks Display
Permit Application
Graces Memorial High School
Bakersfield, CA
October 12, 2012
Bakersfield Fire Department
Fire Station #1
Attn: David Weirather / Fire Prevention
2101 "H" Street
Bakersfield, CA 93301
661 852 -2171 Fax
661326 -3979 office
CONTENTS
Cover Page
Permit Application
Insurance Certificate
Workers Compensation Insurance
CA Pre - Display
MaterialSafetyData Sheet
Transportation. Authorization
California Public Display License
Technician ID
Site Plan
PERMITS & ENTERTAINMENT
PYROTECHNICS
PUBLIC FIREWORKS DISPLAY (Indoor /Outdoor)
ATTACHMENT FORM 1
I
Please print legibly:
a e e S F i o
F/RE
Airm r
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
Phone: 661 - 326 -3979 • Fax: 661 - 852 -2171
Page 1 of 1
APPLICANTS NAM PHONE NO 0 y ` n
il
FAXjJO. 11
2ADDRESS: Ad 1
SPONSORI ANIZ O /, / PHOI P.: 7 '
1n _ -
700
f.Ti9
FAX O.:
r4a
N: R
ADDRESS: c7' pj ( F-/h - it ItpC !-lI/ .
TIMEOFDISPLAY7 J 7-10V4
13D A—t r C
ld'?
T-es
LOCA'nOON O,F DIISPLAY:
ems/ /j
V'6. 19
DATE: TIME:
QG
l ?D on
From a.m.. to P.MJ
Applicant must attach 2 diagrams showing the area and arrangements.)
PERSONS WHO WILL ACTUALLY DISCHARGE THE FIREWORKS AND ARRANGEMENTS (At least two names)
NAME: ADDRESS:
CQl,u.c Si l ati lltl
PHONE NO.:
dKI 3a a- otis?
CA — PYRO LIC #
CA_ag %Q 0 A-
NAME: /
7; -Wt'r
ADDRESS: PHONE NO.: CA — PYRO LIC #
NAME: ADDRESS: PHONE NO.: CA — PYRO LIC #
Kind of Fireworks to be used (Add attachment if necessary) % 3 Size of aerial bursts (Add attachment if necessary) 3
California Public Display License Numbe / GOy1u
Mail Permit to:
Appf t or Firm Nap e
cnrjfj—--1'- ---.- c v v_t--- - - - - --
gnature Applicant
1Li!2-- - - -or
hon
40s _
Date
id1y1r --
DO NOT WR T BELOWTHIS LINE
Remarks and Special Conditions:
Approved T. pector: DateFee: Denied /d — T'
ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
10/4/2012
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 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
Britton- Gallagher and Associates, Inc.
6240 SOM Center Rd.
Cleveland OH 44139
NAME:
PHONE ac NOI:440-544-1234
EMAILADDRESS:
INSURERS AFFORDING COVERAGE NAIC tf
INSURER A:Lexington
1/2012 V112013
INSURED INSURER B:Gran*te State Insurance Co. 23809
INSURER C: Zambelll Fireworks Mfg. Co.
PO Box 1463
New Castle PA 16103 -1463 INSURER D
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 427010688 REVISION NUMBER:
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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRLTR TYPE OF INSURANCE ADDL SUBR
POLICY NUMBER
POLICY EFFMM/DDIYYYY POLICY EXPMM/DD LIMITS
A GENERAL LIABILITY 619391 -04 1/2012 V112013 EACHOCCURRENCE 1,000,000_
PREMISES (Ea occurrence) 50,000XCOMMERCIALGENERALLIABILITY
CLAIMS -MADE KI OCCUR MED EXP (Any one arson
PERSONAL BADV INJURY 1,000,000
GENERAL AGGREGATE 2,1500,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG 2,000 000
POLICY X PRO- LOC
B AUTOMOBILE LIABILITY CA93488094 1/2012 1/2013 Ea accident ) 1,000,000
BODILY INJURY (Per person) X ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY (Per accident)
PROPERTY DAMAGEPeraccidentXNON-OWNEDXHIREDAUTOSAUTOS
A X UMBRELLA LIAB X OCCUR 015374897 1/2012 112013 EACH OCCURRENCE 9,000,000
AGGREGATE 9,000,000EXCESSLIARCLAIMS -MADE
DED X I RETENTION $10 000
WORKERS COMPENSATION WC STATT- OTH-
AND EMPLOYERS' LIABILITY YINANYPROPRIETOR/PARTNEWEXECUTIVE E.L. EACH ACCIDENT
OFFICERIMEMBER EXCLUDED? NIA
E.L. DISEASE - EA EMPLOYEMandatoryinNH)
Ifyes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required)
Display Date: October 12, 2012 Rain Date: n/a
Location: Garces Memorial High School Football Field
Additional Insureds: Garces Memorial High School; Bakersfield Fire Department; County of Kern; Roman Catholic Bishop of Fresno, a
corporation sole, and the employees, officers, volunteers and agents.
Wavier of Subrogation in favor of additional insureds.
Coverage is primary and non -contributory.
P197111I1119L1
Garces Memorial High School
2800 Loma Linda Dr.
Bakersfield CA 93305
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
4
1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
CERTHOLDER COPY
NT
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 10- 04-2012
GARCES MEMORIAL HIGH SCHOOL NT
2800 LOMA LINDA DR
BAKERSFIELD CA 93305 -1724
GROUP:
POLICY NUMBER: 0804630 -2012
CERTIFICATE ID: 174
CERTIFICATE EXPIRES: 08 -05 -2013
08 -05- 2012/08-05 -2013
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08 -05 -2009 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
ZAMBELLI FIREWORKS MFG CO INC NT
PO BOX 1463
NEW CASTLE PA 16103
RMA,CNj
REV. 1-2012) PRINTED : 10 -04 -2012
CALIFORNIA DEPARTMENT OF FORESTRY & FIRE PROTECTION
OFFICE OF THE STATE FIRE MARSHAL
FIRF
P.O. Box 944246
Sacramento, CA 94244 -2460
916) 445 -8373 (916) 445 -8458 Fax HAL
PRE - DISPLAY REPORT
COMPANY: ZAMBELLI FIREWORKS
ADDRESS: P.O. Box 986 Shafter CA 93263
PUBLIC DISPLAY LICENSE NO: GIRD - 1004
Pursuant to Title 19, California Administrative Code § 993.1, we submit the following:
Fields adjacent to
SPONSOR: Garces High School LOCATION: Football Field
DATE OF DISPLAY: October-12. 2012 APPROXIMATE TIME: 8:15 (?
Name and License Number of Pyrotechnic Operator who will Supervise the Display:
Michael Wilson CA 2910 -02 -or- Travis Copeland CA 3287.02
Name and License Number of Wholesaler who will supply display material:
ZAMBELLI FIREWORKS W -1042
Name and License Number of Importer /Exporter Transporting Material for this Display:
ZAMBELLI FIREWORKS I/E -0149
PARTICULARS OF DISPLAY LOW LEVEL ITEMS GROUND DISPLAYS
Shell
Size
No.
Single
Breaks
No.
Multi
Breaks
Shell
Size
No.
Single
Breaks
No.
Multi
Breaks
Type Qty Type Qty
25mm 7" MINES SETS
80mm 8" ROMANS DEVICES
2" 9" COMETS Fountain
3" 100 10" CAKES
4" 11"
5" 12"
6" 16"
Other Items:
I /WE agree to be responsible for compliance with any
October 5, 2012
date)
granted for this display.
Material Safety
Data Sheet
Date lost revised 15 May 2010
I. General Information
Chemical Name & Synonyms Trade Name & Synonyms
Special Fireworks Display Fireworks
Chemical Family Formula
n/a n/a
Proper DOT Shipping Name DOT Hazard Classification
Display Fireworks 1.3g
Manufocturer Manufacturer's Phone Number
Zambelli Internationale Fireworks 800-245-0397 or 724-658-6611
Manufacturer's Address Chemtrec Phone Number
20 S. Mercer St.- New Castle, PA 16103 1 800 - 255 -3924 Chemtel
11. Ingredients
Principal Hazardous Components Percent Threshold Limit Value (units)
Display Fireworks contain explosive and pyro- n/a n/a
technic compositions and are classified as n/a n/a
1.3g Explosives by the U.S. Department n/a n/a
of Transportation. No chemical components n/a n/a
are released during normal handling and n/a n/a
storage of shells. n/a n/a
n/a n/a
Ill. Physical Data
Boiling Point (*F) Specific Gravity (H20 1)
n/a n/a
Vapor Pressure (mm Hg.) Percent Volatile By Volume
n/a n/a
Vapor Density (Air = 1) Evaporation Rate 1)
n/a n/a
Solubility in Water pH
slight n/a
Appearance & Odor
All chemical composition is contained in hard cardboard or plastic casing
IV. Fire & Explosion Hazard Data
Flash Point (Test Method) Auto Ignition Temperature
n/a n/a
Flammable Limits LEL LIEL
n/a n/a n/a
Extinguishing Media
Do NOT attempt to fight fire in vicinity of Display Fireworks - Evacuate Area
Special Fire Fighting Procedures
Evacuate fire area imne t y n a Is F _GV ptablished emergencyahe_1_t_e—r1\ F W a
action plan.
Unusual Fire & Explosion Hazards
Display Fireworks MAy as -1-6de -n-)fire-erit)uation.
to Copyright 1986 6 P,bfishad By ), J. KEUER 6 ASSOCIATES. INC. — Neenah, WI54956-0360 13E•F
V. Health Hazard Data
OSHA Permissible Exposure Limit ACGIH Threshold Limit Value
n /a. n/a
Carcinogen - NTP P -ogram Carcinogen - IARC Program
No
Symptoms of Exposure
Prolonged.exposure to.smoke_ generated during shooting of shells may cause shortness
of.breath..and irritation to eyes and mucus membranes
Medical Conditions Aggravated By Exposure
Persons with pre- existing_respiratory conditions (ie. asthma, emphysema, etc.)
should avoid. inhalation . of
Primary Route(: ) of Entry
Inhalation.-
Emergency First Aid
Move- ,to..fresh,.air .and ..avoid .,further- exposure to smoke.
VI. Reactivity Data
Unstable Conditions To Avoid No open flames, smoking or moisture in vicinity
Stability X ,Stable ,. of stored. fireworks. Avoid friction or impact.
Materials To AvoidIncompatabilityDoNOTallow, fireworks to %et wet.
Hazardous Ma Occur Conditions To Avoid
Polyme6zotion.. . X. „_Will NotOcsur- .... _ ....._ .
Hazardous Decomposition Products Smoke generated during use of these devices may contain small
amounts of carbon monoxide, hydrogen sulfide, nitrogen oxide. Avoid prolonged inhalation.
VII. Environmental Protection Procedures
Spill Response
Cautiously .pick.,up,spilled,material and place in cardboard carton. Absolutly no
smoking, open flames or sparking metal tools in vicinity of spilled fireworks.
Waste Disposo Method
Soak any exposed chemical composition with water. Sweep up with a natural fiber brush
and dispose of by burning in compliance with state and local regulations.
VIII. Special Protection Information
Eye Protection Skin Protection
n/a n/a
Respiratory Protection (Specific Type) Ventilation Recommended
none required n/a
Other Protection
n/a
IX. Special Precautions
Hygienic Practices In Handling & Storage
n/a . . ..
Precautions For Repair & Maintenance Of Contaminated Equipment
Cautiously pick up spilled material,. and _place- in._cardboard- carton.-
Other Precout ons Absolutly no smoking, open flames or sparking metal tools in vicinity of
spilled fireworks.
Za belli* PO Box 986
Shafter, CA 93263
office 661 746 -2842
fax 661 746 -2844
boom@lightspeed.net
TRANSPORTATION AUTHORIZATION
The California State Fire Marshal's Regulations require that an
Authorization to Transport' accompany the driver to validate the
transportation of 1.3g Dangerous Fireworks onto a display site.
According to the CDF / SFM the signed eprmitfortheintendeddisplaywill
serve as this authorization.
However, in many jurisdictions, the permit is not issued until an inspector
reviews the site after the display has been set -up. Thus, no permit is
available 'before- the - fact'.
As an alternative to the display permit, this document, when signed by the
appropriate authority, will serve the intended purpose.
Since trucks are generally loaded at least one day prior to departure,
kindly Fax or Mail this document so that it will arrive at Zambelli's Office
3 days prior to the display date.
AUTHORIZATION FOR ZAMBELLI FIREWORKS
TO TRANSPORT A PUBLIC DISPLAY OF FIREWORKS
into the municipality of
to be held on
Bakersfield, CA
October 12, 2012
display locationGarces HS - Atheltic Fields
is hereby (granted) (denied)
Signature / Date /
Title