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HomeMy WebLinkAboutFIR2016-00055 - FIR Permit / Conditions - 1/30/2016 t MASON COUNTY (360)427-9670 Shelton ext.352 b TA 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 1854 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 I Cis Mason County Fireworks Permit Application Incomplete applications will not be accepted 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: Wolverine West Fireworks Mailing Address: PO Box 628 City: Centralia State: WA Zip: 98532 Phone#: 360.790.3409 Email: aaron@wolverinewest.com Sponsor Information: Name: Alderbrook Resort & Spa Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone#: 360.898.2252 Email: cindy.sund@aiderbrookresort.com Washington State Fireworks License Information (Copy Required): General Display License License Number: C-04138 Date of Issuance 1/30/16 Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: Professional Program Insurance Brokerage Insured: Wolverine Fireworks Display, Inc. Certified Holder: Adam & Anne Farrens Location of Stand/Display: 10 C g I.clR)tb rod e- G1 r t u t _ U n I(jYL Site Address: , Union, WA 98592 Directions to Site: see attached .3a,23 SO - otn l Parcel Number: (twelve digit number) - - Fired on Puget Sound Legal Property Owner n/a **Please see reverse side to complete your application** PART I ® `®® APPLICATION DATE OF APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT 1 A - Ki-6) 1 TO: Governing body of city,town, or countyin which display is to be conducted. -APPLICANT _ _ - NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 360.790.3409 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E Hwy 106 Union, WA 98592 360.898.5529 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Webb 5030 180th Tr. Rochester WA, 98579 P-04311 NAME OF ASSISTANTS: at least one re uired NAME ADDRESS AGE Chad Beebe 11210 Saskatoon Ln Olympia WA, 98506 P-04312 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Resort & Spa - 7101 E Hwy 106, Union, WA 98592 DATE I a 31 ` TIME _rn Icl n I 1�- -NUMBER AND KINDS OF FlikEWdRKS TO BE DISPLAYED - Not to exceed: 15 multi shot cakes, proximate effect gerbs L MANNER&PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines V700M ;_�, SIGNATUlkE OF APPLICANT _FINANCIAL RESPONSIBILITY - BONDING OR INSURANCE COMPANY (Mark One) Professional Program Insurance Brokerage ® Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 371 Bel Marin Keys Blvd. Ste. 220 Bond or certificate of insurance shall provide minimum coverage of Novato, CA 94949 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage r II PERMIT ERMIT# DATE: In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a fireworks display as per the above application. NAME: (Full name of person,firm,or corporation granted permit) RESTRICTIONS: Permit not valid without verification of (Signature of Official granting permit) the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000-420-050(R 02105) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee Alderbrook Resort Aw o� t: e ll�� /� y-J OIVERI,ye VOC9�t;A e • i i wE �./WOMI[5 WEST •� , .. �, Yw Imagery Date 5/5J2013 fat 47.3503Z791on-123:07040P efev 0 ft e i ACC> O CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 5/13/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. 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 endorsements. PRODUCER CONTACT NAME: The Partners Group Ltd PHONE FAX AIC No 11225 SE 6th St., Suite 110 E-MAIL Bellevue WA 98004 ADDRESS: INSURERS)AFFORDING COVERAGE NMC• INSURERA:T.H.E. Insurance Company 19866 INSURED 15539 INSURER B: Wolverine West, LLC INSURER C: Wolverine West Fireworks INSURER D: PO Box 628 Chehalis WA 98532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:325499776 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR N POLICYNUMBER MMIDD/YYYY MMIDD A GENERAL LIABILITY Y CPP010545600 5/1/2016 5/1/2017 EACH OCCURRENCE $1,000,000 DAMAGE REED X COMMERCIAL GENERAL LIABILITY PREMI ET Ea occccurrence $100,000 CLAIMS-MADE a OCCUR MED EXP one $N/A PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE $N/A GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY W INEL)SINGLE LIMIT Ea acddent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS OS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per acrid I $ A UMBRELLA LIAB OCCUR ELP001218200 5/1/2016 5/1/2017 EACH OCCURRENCE $4,000,000 X EXCESS LIAB HCLAJMS-MADE AGGREGATE $4,000,000 DED 1 1 RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ CATIONS/ �CLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Alderbrook Resort&Spa ason Comy&its employees ATIMA are Additional Insured as respects the 713/16, 11/25/16, 12/31/16 Aerial Fireworks Displays locat Iderbok Resort&Spa,7101 E State Highway 106, Union,WA 98592. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Alderbrook Resort&Spa THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 7101 E State Highway 106 ACCORDANCE WITH THE POLICY PROVISIONS. Union WA 98592 AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '! Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal General Display Fireworks License 16-1191 Licensee Data Operational Data Wolverine West, L.L.C. In State Agent: Rodney F. Hash P.O. Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number. C-04138 Date of Issue:January 28, 2016 Date of Expiration:January 31, 2017 State Fire Ma Licensee Signature Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License 16-1329 Licensee Data Rodney F. Hash Phone Number: (206) 459-0917 P.O. Box 628 Email Address: rod@wolverinewest.com newest.com Chehalis, WA 98532 Date of Issue: January 28, 2016 License Number: P-04255 Date of Expiration: January 31, 2017 V State Fire MaqYVLicensee Signature Licensee Wall Mount Card a Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Importer Fireworks License 16-1162 Licensee Data Operational Data Wolverine West, L.L.C. In State Agent: Rodney F. Hash P.O. Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 28, 2016 Date of Expiration:January 31, 2017 State Fire M Licensee Signature Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal s Wholesaler Fireworks License 16-1119 Licensee Data Operational Data Wolverine West, L.L.C. In State Agent: Rodney F. Hash P.O. Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number. C-04138 r. Date of Issue:January 28, 2016 Date of Expiration:January 31, 2017 ' State Fire Ma Licensee Signature