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2004
F 19 ! ! 1. Calendar Year for Application 2. Name of Applicant B Wa Ft fq C c� � 3. Address of Applicant / �°, Contact Person Phone # ( �� .y V `7 4. Is applicant working through a vendor? Yes No ❑ v 5. Name of vendor participating with applicant (if applicable) 6. Address of vendor Contact Person Phone # 7. Is certificate of insurance held by applicant or vendor? Vendor ❑ Applicant ❑ a. If held by vendor, does insurance name applicant and city as additional insurers? Yes ❑ No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # (Name of Holder), Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this applic4ii�n and the sale and storage of fireworks in the City of Blair, Nebraska. j / ttf — jkA App icant Date Vendor (if applicable) Date FOR CITY USE ONLY: Date Received Time Received Applicant awarded license: Yes ❑ No ❑ 6. Address of vendor �A v LA n c �' Ch GC I r pe !�540 h 1o�l l ? Contact Person Phone # 5-33 — WY ®� 7. Is certificate of insurance held by applicant or vendor? Vendor Applicant 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes No 0 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # (Name of Holder) r r I-- tj i C C k., c rk .# 0 r t I X em o r ��o pl. l® //ect: � Uwe, the authorized representative of the above applicant and/or vendor, do hereby make application for a fireworks license to be issued by and through the City of Blair, Nebraska. Uwe further agree to abide by all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this ;applicatio �d the sale and storage of fireworks in the City of Blair, Nebraska. 0 ;6 Appkfcant Date Vendor (if applicable) FOR CITY USE ONLY: Date Received Time Received Date Applicant awarded license: Yes 0 No 0 APPLICATION FIREWORK LICENSE 11 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 11. Sales Tax # 0/ - / ( Name of Holder )!Lhr&- 27 C Uwe, the authorized representative of the above applicant and/or vendor, do hereb make application for a fireworks license to be issued b and through the City of Blair, Nebraska. Uwe fiffffier agree to abide b all regulations and ordinances of the City of Blair, Nebraska and State of Nebraska relative to this application and the sale and stora of fireworks in the City of Blair, Nebraska. Applicaig" Date Vendor (if appli Date FOR CITY USE ONLY: Date Received . -./ I t Time Received Applicant awarded license: Yes El N M NEBRASKA STATE FIRE MARSHAL 4 • South 14th Street / • • 4 Lincoln. • A:. l • • 1 c a LICENSE FOR SALE OF FIREVVORKS Permissible fireworks may be sold at retail commencing 12:01 AM June 25 and ending 11:59 PM July 4 and must be purchased from a .li:censed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for. inspection and must.show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. LICENSE GOOD ONLY FOR JUNE 25 - JULY 4 OF YEAR LICENSE ISSUE This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebrask, Revised Statute 28 -1246 (1994 Supp.). Such license shall be displayed at licensee's place of business. DATE RECEIVED: 4/23i2OO4 TYPE OF LICENSE AND FEE: RETAILER $25 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: VETS FIELD STORAGE LOCATION: 23280 MYNARD RD GREENWOOD NE RETAIL /JOBBER SUPPLIER AND LICENSE NUMBER: B. J. ALAN COMPANY 0045 SALES TAX NUMBER: 17700474 COUNTY WASHINGTON DATE ISSUED: 5/4/2004 STATE FIRE MARSHAL PHANTOM OF NE 938 N 70TH PMB 149 LINCOLN NE 68505- LICENSE NUMBER April 16, 2004 Roger Burris Phantom of Nebraska, Inc. 938 N. 70' Street Lincoln, NE 68505 RE: Firework License in Blair Dear Mr. Burris, The Blair Fine Arts Boosters have been awarded two (2) licenses for fireworks in Blair for 2004. Prior to finalizing these licenses, we will need to receive a certificate of insurance from your firm naming Blair as an additional insured. The Blair Fine Arts Boosters will not be allowed to set up a stand until this certificate has been received. Also, the City of Blair will provide a map within (30) days indicating the location of your stand on the Vet's Field property. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Brenda Taylor City Clerk Lai eoua�NO O "'Ty PP OftTU NETT 218 South 16th Street • Blair, Nebraska 68008 • 402 -426 -4191 • Fax 402 - 426 -4195 . E -mail cityofblair @ci.blair.ne.us -,rise of av COVERAGES THE ANY MAY POLICIES. IN5F2 B POLICIES OF INSURANGE LISTED REQUIREMENT, TERM OR CONDITION PERTA THE INSURANCE: AFFORDED AG LIM S HOWN - -� -- - f _ TYPE OF INS GENERAL LABILITY - - - 1 X CO MMERCIAL GENERAL LIABILITY - I CLAIMS NP.DE , i tJCGLIR BELOW/ HAVE: SEEN ISSUED TO THE INCSLIRED OF ANY' CONTRACT OR OTHER BY THE POLICIES DESCRIBED HEREIN MAY HAVE BEEN REDUCED BY PAID ` -- --! POLICY NUMBER _ 5433935 - ; NAMED ABOVE DOCUMENT WITH IS SUBJECT CLAIMS. POLIO EFFECTIVE �jj DLL .--DAM 10/01/03 I i FOR THE POLICY RESPECT TO WHICH TO ALL THE TERMS, POLICY EXPIRATION dM 1 _ 1 � D A' 10 /OIJ0.4 PERIOD INDICATED, NOTWITHSTANDING THIS CERTIFICATE MAY BE ISSUED OR EXCLUSIONS AND CONDITIONS OF SUCH _ LIMITS _ - - -- EAC OCCU $ 100000{} -- FIRE DAMA (Any cineflre) NED EXP (A ny une pers on) PERSONAL & AD !NJU RY_i $ 50000 — $ - -_ -_, -- $ 1000000 - - - - -- GENERAL AGGREG P RMLI C TS - COP /P /CJP A GG $ 2 00 000 0 $ - - - -- - - I f --- tiEN'L P,GGRECATE LIMIT .4 ?P PER: t POUCC J L DC AUTOMOBILE LIABILITY P.NY AUTO - I ALL OWNED AUTOS ' ---III I ( `- { COMSINED SINGLE LIMIT (Ea amiccnt) - •_,___ _ BODILY INJURI' (Per parson) $ - -- -� SCHEDULEDAUTOS HIRED AUTOS NON-OWNED AUTOS I � i i ! - - - - - -- r(P ODILY INJURI' ar arcldertj -- $ - -� - -- -- -` - -- PROPERT`/ DAMAGE l AUT ONLY - EA ACC IDENT � EA ACC OTHERTHAN AUTO ONLY: AGG - $ GARAGE LIAINILITV -� ANY AUTO A LXCESS LIABILITY � x] JCLUR CLAIIMS MADE 3.9 4dt7LP1 A00,0 { � 10/01/03 ( 10/01/04 EACI OCC --- $ 4000000 ~ - -��- - AGGRE $ 4000000 - - - --- - J ' - -- - - - DEDUCTIBLE $ 10000 RETENTION 1Og00 VIItlRKER9CIyMPEN3/+tTIUIt EMPLOYERS' LIABILITY _______.r�.r��._.. -) _____ __�___ - -- $ 1NC S OTN- JIu _1 --P - --- ._-_ -_ E.L. E ACH ACCIDEN -� $ - C flTtiER >3xcasa Liability (over Arch Specialty) + 10/01/03 I ` I 10/01/0 E,L. DISE ASE _EA EMPL $ -- - —� $ DISEAS - POLICY LIh /IT 5,004,000 DESCRIPTION OF OPERAMONSILOCATIONS11tEHlCLESIEXCLUSIONS ADDED BY E-NDORSEMENTISPECIA PROVISIONS PRODUC LIABIA LIT'Y BXTENDS ONLY ------------------- r _.1..1.. I TO pRODTj( PURCRASED PROM - .°' _'_ , B.J. ALAN COMP3LNY•�OR _ - _ . - -. . .. DIAMPPI) - ..r.. r SPA C O.: INC. ChK I IB 1 1W 111alLU K I I AUU1IIVNAa. I N*W r-U; onaun6m - SHOULD ANY OF THE AacjVC DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BLAIR i ,JIGH SCHOOL FIRE ARTS BOOSTER DATE THEREOF, THE ISSUING INSURER WILL EiNDEAVt7R Ta MAIL _30 _ GAYS WRITTEN ?A" TTY A 14INNINOUR NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $LR SHALL IMPOSE NO OBLIGATION 13R LIABILITY OF ANY 14IND UPON THE INSURER, ITS AGENTS OR 1217 PINEWOOD DRIVE R EP RESENT ATIVES. _ „ — •-- -•- BLAIR, NE 0008 P,IJ7HORIZED REPRESENTATIVE USA AOORD CORPORATION 1988 AICORD 25-S (7197) BOALANO6 1/11 / oW PaWered E3 TN Y I�: a 12iJYic a ff's t�tc� tiv .....� vv, va 4. "'P .L °tlJt.�'3'tLC?Lt� Pg 2/6 t'8 .71 0 If the certificate holder is an ADDITIONAL INSURED,. the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A , statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), D IS.CLA MER The Certificate. of Insurance fln the reverse side of this fnrrn does not conztit! Ire a ccntract "n`,�vlaQr the issuing insurer(s), authorized representative or producer,. and the certificate holder,. nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listen thereon. ACORN 25 -S (7/97) vV11111idt11Gl. — / 1`t 3 jig g/tj Additional Insured -- Vendors Paragraph 5. is added to Section II - WHO IS AN INSURED as follows: Any person or organization acting as a vendor, but only with respects to "bodily injury" or '`property damage" arising out of "_your products" which are distributed or sold in the regular course of'the vendor's business; however, the insurance afforded to a vendor does not apply to: a. "Bodily injury'' or "property damage" for which the 'vendor is obligated to pay damages by reason of the assumption of liability in the contractor agreement. This subparagraph does not apply to liability for damages that the vendor would have in the absence of the, contract or agreement; b. Any express warranty unauthorized by you; c. Any physical or chemical change ii' the product matte intentionally by the vendor; d. Repackaging unless unpacked solely for the purpose of inspection, denionstration, testing, or the substitution of pants under instructions from the manufacturer, and then repackaged in the original container; e. Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or nc r rally undertakes to make in the usual course of business, in connection with the distribution or sale: of the products; f: Demonstration, installation, servicing or repair operations. except such operations performed at the vendor's premises in connection -vNvith the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, or any other thing or substance by or for the vendor. This insurance does not apply to any insured person car organization, ti whom you have acquired such products, ter any ingredients, part or container, entering into, accompanying or containing such products. Additional Insured - Blanket Paragraph 6. is added to Section TI - WHO IS AN INSURED as follows: Notwithstanding any term or condition of this policy to the contrary, any person or organization required by written contract to have liability coverage for operations performed by the Narned Insured on behalf of such person or organization will qualify as an additional insured for such coverage as is provided under Coverage A. In addition, a lessor who leases a location to the Named Insured and is required by written contract to have liabilityicoveragc for operations performed by the Named Insured on behalf of such lessor will qualit7 as wi additional insured tin' such coverage; as is provided under Coverage A. — -_.. —.. •...— I .a. �v L%a'S Z L W daV 70rtgaaph is added to Secti II . \VH(,) IS A NI SU D as faltaws 5. A ny person or onion wfiIo hold a cettjr IcIte Of iASUranc: for "nt;ia-vw ed stands" the �tg(� ratn� t�'+�'ith YOU, UT Orly for Habilirrt with msv= to w bodilu_,i[�)'U r��s v 760�?CaZ C3�lZYLr� C," vv '�' U4 ` ir_j"Ty." �C71�V,V�r 21 - p= ovided jundert jaramri7p:l is linaitcd to dxose cert9riCute ai �1 Lain 1ert cc c litsuc�acicN prior to tine - co rtzrr c ;, and whusc ccrditcate Of 41r mnu is ort file with Uy; Ud b- COY prQ - v ided Andez thij paragraph is ' ijnit:d bn desi�,at�d "nnn fOr� the time period spt- 0rLcd in r �ic c�rtt a�n rkf` ia..tiilr�laae. .r�. �recl an tla;s enr ar e► ac, `un red spuds'' mtans x:IY PTemis4s. Size or 10cat uA wh ich 14 uwue 1, o r- cc by, o car nd 4i' loaned m a eer'ti a -cata a 63 -Wry; a 110k0 t, itl��l'udi;1 z CeaYl rar r stTCrr��re ; �7st d fr�rffir, r�tr�i2 .snl c� th Nu d1mirred's pyrate0mit vmducts, germs, conditions and exceusi4r.s remliaa u =b=ged ' a �s Akl t aar' ed RepreStTL 16101 .� k-8 :A 10 SUPP LEMENT T CERTIFICATE F INSUR DATE o3 /as / ©4 NAM COFI Pi's URED: E.J. Alan Company �•• Big Bear Fireworks, Inc. ADDENDU13 A ?sttactunsnt to Certificate of Insurance for: E.J. ALAN COMPANY Big Bear Fireworks Ph&ntoxn Fireworks The Certificate Balder, the i°_allowi.hg Organizations, Interests of the Property and Municipalities aria included as ,Additional Insured as respects liability coverage (Vendors Endorsement and Premises Liability) as their interests nay appear, C•artif'cate KOldera BLAIR HIGI3 SCHOOL FINE ARTS BOOSTERS .Locatieuy, VET'S FIELD, ;?LA:IR,, NE Property Owner: CITY OF BLAIR Additional Insured: BLAIR HIGH SCHOOL FIRE ARTS BOOSTERS Mun.idiPal.ity: BLAIR, NE 61008 Its officers, agents, employeen and �vol,untee:ras when acting in their official capacity, PP (1 440 PA G E : 21 LIABILIT ' DATE (MM /DDMYO ACOR 05/11/2004 PRODUCER (440) 248 -4711 FAX (440)248-5406 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton - Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cleveland, OH 44139 INSURED B ,7 Al an Company 555 Martin Luther King Jr. Blv Youngstown, OH 44502 r-wco -rte INSURERS AFFORDING COVERAGE NAIC # INSURER A: Lexington Insurance Co INSURER B: Granite State Insurance Co. INSURER C: Arch Specialty Ins Company INSURER D: Axis Specialty Ins Company INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MM /DD DATE MM /DD LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR 5433938 10/01/2003 10/01/2004 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED $ 50,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: P PRO OLICY - JECT X LOC PRODUCTS - COMP/OP AGG $ 2!5000,000 B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CA626 51461 10/01/2003 10/01/2004 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ C EXCESS /UMBRELLA LIABILITY X OCCUR 7-1 CLAIMS MADE DEDUCTIBLE X RETENTION $ 10,000 42ULP1435000 10/01/2003 10/01/2004 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 $ $ U WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below OTHER Excess Liability over Arch Specialty AAU704353 10/01/2003 10/01/2004 WC STATU- OTH- I TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ 5,000,000 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS r FRTICIrATC Uni neo City of Blair Brenda Taylor 218 S 16th St Blair , NE 68008 ACORD 25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE © ACORD CORPORATION 1988 . • so If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) t April 16, 2004 Rich Ludvik AID Ka- Boomers Fireworks P.O. Box 86 Wahoo, NE 68066 RE: Firework License in Blair Dear Mr. Ludvik, The Blair Jaycee's have been awarded a license for fireworks in Blair for 2004. Prior to finalizing this license, we will need to receive a certificate of insurance from your firm naming Blair as an additional insured. The Jaycee's will not be allowed to set up a stand until this certificate has been received. Also, the City of Blair will provide a map within (3 0) days indicating the location of your stand on the Vet's Field property. If you have any questions or need additional information, feel free to contact me. We look forward to working with you for a safe and profitable fireworks season. Sincerely, Brenda Taylor City Clerk EQUAL HOUSING GPPO NTUNITT 218 South 16th Street • Blair, Nebraska 68008 a 402 - 426 -4191 • Fax 402 -426 -4195 • E -mail cityofbialr @ci,blair.ne,us ►pp • O 1. Calendar Year for Application 1 Name of Applicant Blair Jaycee's 3. Address of Applicant �.,� ' . q G.o 6C e- 6 ,p, Contact Person Ron DeSutter Phone # 402 - 533 - 3259 4. is applicant working through a vendor? Yes C No ❑ 5. Nance of vendor participating with applicant (if applicable) Ka- Boomers Firework 6. Address of vendor PO Box 86 / Wahoo , NE 68066 (1 2 5 8 County RD 18 ) Contact Person Rich Ludvik Phone # 402 -443 -4593 T Is certificate of insurance held by applicant or vendor? Vendor Applicant ❑ 8. If held by vendor, does insurance name applicant and city as additional insurers? Yes 1Z No ❑ 9. License fee - $5,000 (Attached) 10. Certificate of Insurance (Attached) 1 1. Sales Tax # 15671981 (Name of Holder) Ka Fi s FOR CITY USE ONLY: c Date Received I o q Time Received Applicant awarded license: Yes ❑ No D FROM : s I 1 FRX NO. : 4029649499 Jun. 03 2004 06:48RM P2 ALLIED SPECIALTY INSURANCE AID TEXAS TEXAS T821C $5 NE LOOP 41tD, SUI 210- 341-1321 certificate Number t 00108 amends extends or This certificate neither affi.xmatheelelicr described hereon and is issued r ff ca alters the coVeae orded p y anconfers confe� no right up ©n the holder as a mattes of Ln aorm�.t� -on olio t ies ) identified below by a policy number i s i.x� fence on the date of The v Insurance is o�ded only with respect to those cert' f i.caKe issuance. coV era es for which a specific limit of liabilie�ceathereto nngthi,ngnherein sub �aine shall t erms modify anyelprovisionaofn$aid policy. con olic I n the event of cance of the ' Pnoi- He�i�e °�annoollati toathep y will �mai�e all reasonable effort to se Certificate Holder at the adtake�orhfailureeto give suchCnotice.assumes no responsibilities,- for any mic associat ins�uranc+e made a part of the olicy includes a$ a enson site- ins ure d ) the Fair h ,Any ace at a F`ireworku San Bite ; respect to an occurxenCe' taking p 2) t or exhibition sponsoring organization or committee t 2 ) t,k�e owner or lessee thereof C 3 ) a muniai ali.ty granting the Hawed Insured p ro ert operate a(n) Fireworks Stand but obi -Yth� rries�i.genceoc�flKhe amed Mred y damage caused by or coxxtr'ibund to y of their employment. g .sty, 1 � actina in the coursac and to NAHE A ADDRESS OF is SURED I : X Enterp r P.O. Box 86 Wahoo MB 68066 N., %E & ADDRESS OF CERTIFICATE HOLDER'- City of Blau 218 south 1 6th street Blair, NE 66008 �► UNARY COVERAGE campany: T.H.E. Insurance Company ADDITIONAL INSURED City of Blau & Employee' S Blair Jaycee's STAND LOCATION Nets Field 13th & Butler Blain NE 68008 EXCESS COVERAGE polio y Number M4MT3362 Bodily In ury & bodily In ury & LABILITY UNITS proper age Property kma.ge L aCC 1 600 +�tll0 $0 p er )' �a $0 BI IPT� ` AGO xcess o xcess n pr oducts: 000J ®00 policy Period: 0f1/04 00/00/00 00/00/00 From: 00 00/00100 To: 05/15/05 � COMBIHED SINGLE i.,I31I'I' CoveM -ars e shown herein applies only to those items s,;beduled on or endorsed to the . T �.s cer-��.�cete s not va,�.3.d unl.ams an origi..n�a�7. s�.gnnture app below. WopiL -s got Valid). all insureds coverage vender the policy is FQr� ot l tibnAssociat ;on (NFPA) codes and with all applicable National standards In effect at the time the stand is open. .dune 2 2004 .A � A r rPo r,Mr — sit a Y \/ 1 >1/1i rr. 11 %L^t (k 4 1''. W FAX N0. : 4029649499 Jun. 03 2004 06:48RM P1 NEBRASKA STATE FIRE L 246 South 14th Street Lincoln. NE 68508 -1804 _ 4 LICENSE FOR SALE F FIREWORKS Permissible fireworks may be sold at retail commencing 12;01 AM June 25 and ending 11:59 PM July 4 and must be purchased from a licensed distributor or jobber. A jobber may not sell retail. Invoice copies for all fireworks must be kept available for inspection and must show the license number of the distributor or jobber. Fireworks may not be sold outside the city limits of an incorporated town or village. Violations of State Fire Marshal regulations may result in immediate revocation of this license. LICENSE GOOD ONLY FOR JUNE 25 - JULY 4 OF YEAR LICENSE ISSUE This copy signed, dated and numbered by the STATE FIRE MARSHAL constitutes issuance of a LICENSE pursuant to the provisions of Nebrask, Revised Statute 281246 (1994 Supp.), Such license shall be displayed at licensee's place of business. DATE RECEIVED: 5/1 3/2004 TYPE OF LICENSE AND FEE: RETAILER $25 LOCATION OF OUTLET FOR RETAIL SALE OF FIREWORKS: 13TH & BUTLER STORAGE LOCATION: 1258 CO RD E WAHOO NE RETAIL /JOBBER SUPPLIER AND LICENSE NUMBER: KA- 800MERS ENTERPRISES INC 0019 SALES TAX NUMBER: 1567981 COUNTY WASHINGTON DATE ISSUED: 5/19/2004 STATE FIRE MARSHAL LICENSE HOLDER: 1/2 PRICE FIREWORKS P O BOX 86 LICENSE NUMBER WAHOO NE 68066- 200 4-0594