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KITTITAS COUNTY FIRE MARSHAL'S OFFICE <br />411 N. Ruby St., Suite 2, Ellensburg, WA 98926 <br />is Office (509) 962-7657 Fax (509) 962-7682 <br />Fire Marshal "Special Event/Assembly" Permit <br />Application Date: 'rj <br />j,(j (� ❑ Initial ❑ Renewal <br />Pertx>it #: <br />Event Permit (Temporary) Title of Event: <br />L�•�y <br />Dates/rimes of Event: *.2.N+ J Y S ��� _ 1 I}'� p���'�� r C (� <br />Physical Location of Event: kci de* br k., & E k1hi f W/t yg j t � ❑ Indoors Outdoors <br />��C• V, <br />Event Coordinator : f tl - Phone #: t50q. �� • L� O Cell #: <br />iE[. �/ j T o •��. • 55ca <br />Mailing Address City rJ_� n St WA- 176 Email: <br />/ STI , <br />❑ Assembly Occupancy (Permanent) Specific Use of Building: <br />Physical Address: Assessor's Map #: <br />Building Tanant : Phone #: Cell #: <br />Mailing Address City St Zip Email: <br />Building Owner: Phone #: Cell #: <br />Mailing Address City St Zip Email: <br />060ra.0M"tidn: (dnLy: tegainA for Assembly 0ouWaney Permits) <br />SUM <br />MON: <br />TUE: <br />WED: <br />THU: <br />77— <br />SAT: <br />Specific Description of Operation/Event: (Required for both permits) <br />in gNj th gi <br />nj'4h. a+p"ff 4jQA WOO -1W a*noLa� <br />Food/Beverage? YES NO <br />Alcohol Served?5 No <br />Live Entertainment? ES) No <br />Security On Site? ES NO <br />Tents? #of YES (7 <br />Stages? #of _� Y15 NO <br />Emergency Contact: Phone #: <br />t -ma. - r Ja- 5oq co14 • wb-'s <br />After Hours: Phone #: <br />9.30e" 5c�. 3 8.1814 <br />I hereby state that the above information is correct. I agree to comply with all requirements related to this <br />Event/Assembly Permit. I further agree to, and hereby grant to the Kittitas County Fire Marshal's Office the <br />right to enter onto the premises as described for this permit application, for the purpose of making such <br />inspections and tests as may be required. This permit is valid until renewed, revoked, or expired and is non- <br />transferrable. <br />Owner / Au ori2ed Agent II ((L�� <br />Signature: Print Name:AO–k T, <br />Title: G� rL Az+15444 .zi <br />—Date: <br />Version 2009.2 <br />