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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 />-W <br />Fire Marshal "Special Event/Assembly" Permit <br />Application Date: 45(O(LLJC5 <br />❑ Initial ❑ Renewal Permit #: <br />Event Permit (Temporary) Title of Event: ^^ .. � ��� + Vee , rd <br />rl <br />Datesaimes of Event: Q �I S t � O 0,4 &PdA (tA-y �- a C V <br />�' <br />Physical Location of Event: 2r� I f , j , e j [) V �e' (1 / e C(v , t _ /� %9 r7 ❑ 1nd00iS <br />pC �OUtdOOrS <br />V `-�j/ <br />`'j��}(j`. (,eg2 <br />Event Coordinator : 1 Le -"am Phone #: 2 („ Cell #: 2 .5,75Co <br />• 1 <br />�h <br />Mailing Address 1[b , ^� I City �iJ SSttwJ ZJip Fiaai <br />{"C J f 11-L+lf -tkw/k ODSVVr F <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 #: <br />Mailing Address City St zip Email: <br />rl��n; ��rt,t,�r��i�,� ton►p,#�tiiiwi�l �lf�s,ul�sy r,t:ououi>cv P.tyfniis) - - <br />SUN: MON: TUE: WED: THU- FRI: SAT: <br />Specific Description of Operation/Event: (Required for both permits) <br />r <br />v►r i Awa �-e.4ia.r S ILry\a - 70b <br />Food/Beverage? E No Alcohol Served? No Live Entertainment? Ys S No <br />Security On Site? E NO Tents? #of YES NC1 Stages? #of _� Y. NO <br />Emergency Contact: Phone #: After Hours: Phone #: <br />L-cXla. �-� 5oq. (74, �5 <br />1�— <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 exph•ed and is non- <br />transferrable. <br />Owner / Authorized Agent <br />' <br />Signature: Print Name:evlt-4cC <br />VC S`- PjIOne #: 5M • 852. 7 3 ( D <br />Version 2009.2 <br />