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KITTITAS COUNTY FIRE MARSHAL'S OFFICE <br />q 411 N. Ruby St., Suite 2, Ellensburg, WA 98926 <br />Office (509) 962-7657 Fax (509) 962-7682 <br />Fire Al ars)) al "Special Event/Assembly" Permit <br />Application Date: �5ct I 2D 1,5 ❑ Initial ❑ Renewal Permit #: <br />Event Permit (Temporary) Title of Event: <br />"iF,&4 <br />Dates/Times of Event: <br />n <br />n ^ I cors CLr +- crds- <br />!I <br />Physical Location of Event: <br />,-P fOPC ,� p ri V2, L E(07 � V%rT ��. L1 Indoors WOutdoors <br />Event Coordinator: ` �r� n J , Phone #: j5ul , K2. -42 (D Cell #: � � 2-.4379(a <br />Y <br />I �j1{[�j� <br />`h <br />Mailing Address n city 1V Sin F zip I:nwi <br />`j -1L 1 f� ��i+IIC� <br />❑ Assembly Occupancy (Permanent) Specific Use of Building: <br />Physical Address: Assessor's Map <br />Building Tenant : Phone #: Cell #: <br />Mailing Address City St zip Email: <br />Building Owner : Phone #: Cell M <br />Mailing Address City St zip Email: <br />Rings of y&ratr9m (Duly. Rejultut fare><asemhty[icau nuy ltcrruira} <br />SUN: <br />MON: TUE: WED: -T <br />THU: <br />PRI: SAT: <br />Specific Description of Operation/Even11t: (Required for both permits) <br />i T t r <br />Food/Beverage? NO <br />Alcohol Served? NO <br />Live Entertainment? YES NO <br />Security On Site? NO <br />Tents? #of YES N[3 <br />Stages? #of _� YL5 NO <br />Emergency Contact:. Phone #: <br />LOWCC, -{aa ' 0-, 5d q . o-+ 05fb <br />After Hours: Phone #: <br />C .3o C . , ,. i 814- <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 / Authorized Agent <br />Sigrlatt�re: Print Name: p <br />Ph tIc 5 7-3( Q Date: <br />Version 2009.2 <br />