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KITTITAS COUNTY FIRE MARSHAL'S OFFICE <br />411 N. Ruby St., Suite 2, Ellensburg, WA 98926 <br />Office (509) 962-7657 Fax (509) 962-7682 <br />Tire Marshal "Special -Event/Assembly" Permit <br />Application Date: rj(ct 2D1 C5 ❑ Initial ❑ Renewal <br />Permit M <br />Event Permit (Temporary) Title of Event: ` <br />Dates/Times of Event: `LT -4 C, I E) 4000Y"9 Open 47tUP P L4 •r u y, C A -S �- �O <br />to rte{ PKA <br />Physical Location of Event: 2 1 f D ,*/ p Y -I �e/ (1 / e E(UWL t. A 1:0j � ❑ Indoors Outdoors <br />V <br />(,,[] <br />Event Coordinator : I 1 f� � Phone #: �`J(,�jJ`.* <br />-v 2 ('110` Cell #: 5 2-579( 0 <br />`� [j 5,2 . cI <br />Mailing Address (]/� City �V S1.VV k Zip I mai 6 t <br />Tb &x}'� L <br />❑ Assembly Occupancy (Permanent) Specific Use of Building: { <br />Physical AdJress: Assessor's Map <br />Building To" : Phone #: Cell #: — — <br />Mailing Address City St Zip Email: <br />Building Owner Phone #: Cell #: <br />Mailing Address City St Zip Email: <br />13pL115iyS'{)jSisl11UP. I : {C]III ftequir'A f6r AwMhly f h' -C (JY inGy Ct;rIII iLs) <br />SUN: <br />MON: <br />TUE: <br />WED: THU; <br />FRI: <br />SAT: <br />Specific Description of Operation/Event: (Required for both permits) <br />4 r <br />Vt �� GcAars, i p!2,g - --?ov <br />Food/Beverage? No Alcohol Served? s No <br />Live Entertainment? YES NO <br />Security On Site? S NO Tents? #of YES L02 <br />Stages? #of _� YES No <br />Emergency Contact:Phone #: <br />Lf-iC,n�- <br />After Hours: Phone #: <br />� • 3�5. f <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 / Autharied Agent <br />Signature: Print Name: p CZ7 M41all <br />VQ. <br />Version 2009.2 <br />u <br />l7 <br />