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KITTITAS COUNTY FIRE MARSHAL'S OFFICE <br />Ilk411 N. Ruby St., Suite 2, Ellensburg, WA 98926 <br />Office (509) 962-7657 Fax (509) 962-7682 <br />Fire Marshal "Special Event/Assembly" Permit <br />Application Date:, <br />?p ( ❑ Initial ❑ Renewalcrmit <br />#t <br />JU Event Permit (Temporary) Title of Event: Op <br />Dates/rimes of Event <br />N&I /� h 14 � 1 . py / + �C�_ + <br />Physical Location of Event: "?,�Uf I r%cp RAO- briYG, CIe EIrtim,W/f 981A� ❑ Indoors �. Outdoors <br />v' <br />Phone #: /q� IZ2 . 1.+1 ( O Cell #: r . <br />Event Coordinator : ►.i T v7St%A- <br />Zip G�q,� Email: <br />Mailing Address P-D�)c 1"2 City Vj_d�{rN <br />❑ Assembly Occupancy (Permanent) Specific Use of Building: <br />Physical AdJjm: Assessor's Map #: <br />DuMng Tenail : Phone #: Cell #: <br />Mailing Address City St Zip Email: <br />Building Owner: Phone #, Cell #: <br />Mailing Address City St Zip Email: <br />tlogrc of tlpA lo�: .�IfLiipited fQr A5S 1173y:t]Ct)1p3AC� PZxmifG} - ` - .. _ - - <br />SUN: MON: <br />TUE: <br />WED: <br />THU: <br />FRI: <br />SAT: <br />Specific Description of Operation/Event: (Required for both permits) <br />'t n -I' - [ <br />u�'wNn, a.Wi'tfi2± LOCO f00 aAcrid-94-6- <br />Food/Beverage? YES NO <br />Alcohol Served? NO <br />Live Entertainment? s NO <br />Security On Site? ripNO <br />Tents? #of YES [) <br />Stages? #of _� 7'E5 NO <br />Emergency Contact: Phone #: After Hours: Phone # <br />bdma� j°�. 5oq (o A- . t�6 C' 3Dp� <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 t Ariz Agent <br />Signature: Print Name: <br />DIC: E 1 I Y P1ione 2 Date,. <br />Version 2009.2 <br />