HomeMy WebLinkAboutFIR2013-00030 - FIR Permit / Conditions - 8/16/2013 § 0
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MASON COUNTY (360)427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext. 352
BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext. 352
Mason County Bldg. III, 426 West Cedar Street
R54 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us
FIR20 )3 - 000-30
Mason County Fireworks Permit Application
Incomplete applications will not he accented
A permit for retail sales or public display of fireworks is required. A completed
application with required documentation and fees shall be submitted for Fire Marshal
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information:
Owner: �2t,Yo + rif-e, �X LLCM
Mailing Ad ess: PO Roc l613 City: i v State: Zip:P'q K 335
Phone#: �j(oo - Z°[l- 07 Email: T�0 0..hart_ �x @�rnabL
Sponsor Information:
Name: d- e
Address: SLo City: 5pA-4� State: Wyk Zip: 9g_�4�
Phone#: 4a.Fp - }-7R - 9 c}- 4 Email:
Washington State Fireworks License Information (Copy Required):
rnta eup. I
3
License Number: Pb43j� Date of Issuance 1 1 a 4 1
Pyrotechnic Operator License LiFireworks Stand License
Bond or Certificate of insurance (Copy of Certificate/Bond Required):
Provider- A A m wal Co.
Insured: YHA* Fkr4� FX Ll z-,
Certified I461der:
Location of Stand isplay. ` �
Site Address: 10 0. L w
DirectionstoSitelAovl�d7>Z S aYk t7an� Sir
Parcel Number: (twelve digit number)
Legal Property Owner N A or
"Please see reverse side to complete your application"
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNY) 7/29/13
PRODUCER THIS CERTIFICATE DOES NOT AMEND,EXTEND ORALTER
THE COVERAGE AFFORDED BY THE POLICIES BELOW.
DRAYTON INSURANCE BROKERS,INC.
P.O.BOX 94067
BIRMINGHAM,ALABAMA 35220
(205)854-5806 INSURERS AFFORDING COVERAGE
INSURED INSURER^: ADMIRAL INSURANCE COMPANY
Pyro& Fire FX, LLC INSURER B:
P.O. Box 193 INSURERC
Gig Harbor, WA 98335 INSURER°:
INSURER E:
COVERAGES
I HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQGIREMENT,
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W ITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDCCED BY
PAID CLAIMS.
INSR. POLICY POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER EFFECTIVE DATE LIMITS
DATE
GENERAL LIABILITY EACH OCCURRENCE $5.000.000
X COMMP.RCIALGENERALLIABILITY LIRBDAMAGE(Anyone Fuel $ 50.000
p Y IX'CURRRNCE CLAIMS MADE CA000003209-23-1110 6/21/I3 4,17/I4 MEDCXP(Any— $ NONE
PERSONAL&ADV INJURY $5 000 000
GENERAL AGGREGATE $6,000,000
(TEN'L AGGRFOA'I'F.LIMIT APPLIES PER PRODCCTSLOMP/CAP AOQ $IDG1UdBCI
,A' POLICY PROJECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB
_ANY AUTO GGe .dOM) $
ALLOWNFD At NOTCOVERED BODILYINJURY
_SO HEDL LED AUTOS (P� pe—) P�
_ HIREDAUI'OS BODILY INR'Rl
_ NON OWNED AUTOS (P--dem) S
_ PROPERTY DAMAGE
(Ptt amidenf) �'
GARAGE LIABILITY NOT COVERED
EXCESS LIABILITY EACH OCCORRP.NCP $
_ OCCUR CLAIMS MADE AGGREGATE S
NOT COVERED $
DEDUCTIBLE $
RETENTION S $
WORKERS'COMPENSATION AND
EMPLOYERS'LIABILITY NOT COVERED
OTHER
A 1 Stop Gap Liability CA000003209-23-1110 4/17/13 4/17/14 $500,000
DESCRIPTION OF OPF.RATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Mason County,Mason County Fire District#6,Alderbrook Resort and Spa, Megan Fouty, and Michael Lutes are included
as Additional Insureds in respect to liability caused by the Named Insureds operations,except that coverage does not apply
to liability caused by the Additional Insureds negligent acts or omissions.
CER1 IFICATE HOLDER
Mason CODnty SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
l• EXPIRATION DATE.THEREOF,NOTICE WILL BE DELIVERED IN ACCORD 4NC E W ITH
426 West Cedar Street THE POLICY PROVISIONS.
PO Box 279
Shelton,WA 98584
AUTHORIZED REPRESENTATIVE
RECEIVED
A J.Stringer