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Home My WebLink AboutFIR2016-00023 - FIR Permit / Conditions - 6/30/2016 Inspection Line (360)427-7262 PgO� cot,,�A.... MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Phone:Inspection Line ( 60) ext.262 Mason County 615 W Alder Street Shelton, WA 98584 FIRE PROTECTION PERMIT FIR2016-00023 APPLICANT: WOLVERINE WEST FIREWORKS RECEIVED: 6/21/2016 CONTRACTOR: LICENSE: EXP: ISSUED: 6/30/2016 SITE ADDRESS: 10 EALDERBROOK DR UNION EXPIRES: 12/30/2016 PARCEL NUMBER: 322335000014 LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58 PROJECT DESCRIPTION: ALDERBROOK RESORT FIREWORKS DISPLAY FOR JULY 3RD, 2016 GENERAL INFORMATION System Information Type of Use: DIS Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 6 Flow Switches: Visual Devices: Door Releases: Hood& Duct?: Pressure Switches:: Smoke Detectors: Duct Detectors: Dry Chemical?: Zones: Heat Detectors: Wet Chemical?: Sprinkler?: Standpipe?: SQUARE FOOTAGE FEES Monitoring Company: First Floor: Type Amount Due Amount Paid Monitoring Phone No.:() - Second Floor: Fireworks Display Permit $250.00 $250.00 Auto Fire Alarm?: Third Floor;: Total: $250.00 $250.00 FIR2016-00023 Please refer to the following pages for conditions of this permit. Page 1 of 4 ,CASE MOTES F I R2016-00023 CONDITIONS FOR FIR2016-00023 1 ) 1 Must ply with RCW 70,77. X OWNER f BUILDER acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Ackr owledgement of such is by signature below. I declare that I am the owner,owners legal representative,or contractor I further declare that I am entitiel to recei to this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of,iterest rr garding this project. The owner or authorized agent represents that the information provideo is accurate and grants employees of Mason County access to tl a above described property and structure(s)for review and inspection. This permit/apoiication becomes null&void if work or author iced construction i4 not con- henced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTIOI I.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. Signature ` Dat L�✓fir,, Q :� OWNER - REPRESENTATIVE Cr NTRACTOR Print Name (Circle one to 1ndi,.ate) f: FiRZ016-It}OQ23 Please refer to the following pages for conditions of this permit Page 2 of 4 I 9oN Cot, MASON COUNTY (360)427-9670 Shelton ext.352 �" Tf 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 18.54 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 Itp - WOR 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@alderbrookresort.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: Site Address: 7101 E WA-106, Union, WA 98592 Directions to Site: see attached ,_5aa33- so Parcel Number: (twelve digit number) - - Fired on Puget Sound Legal Property Owner n/a "Please see reverse side to complete your application" The following pertinent information MUST be provided on the site diagram below Location and Setback distances from the back, sides and front of retail sales stands or designated display areas to: Fire Hydrants Property Lines Mortar separation distance Combustibles Parking Designated landing area Fire Lanes Public Roads and Right of Ways Trees/Brush Private Roads and Right of Ways Utilities Landmarks see attached Applicants Affidavit I certify that the information provided herein is accurate and that compliance with all County, State and Federal laws pertaining to the sales or discharge of fireworks shall be maintained. Digitally signed by Aaron R.Webb Signed DN:cn=Aaron R.Webb,o=Wolverine West, Date 6/14/16 Aaron R. i�o„=ni�plyy Nla aoe, email=aaron@wolverinewest.com,c=US Aco CERTIFICATE OF LIABILITY INSURANCE FDA TE(M MDD/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 NAME: The Partners Group Ltd PHONE 4 4 Fac No:4 ] ] 11225 SE 6th St., Suite 110 EMAIL Bellevue WA 98004 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A INSURED 15539 INSURER B: Wolverine West, LLC INSURERC: 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. 1�7R POLICY EXP TYPE OF INSURANCE AIN R SWVD POLICY NUMBER MUBR M/DDYIYYYY MM DD/YYYY LIMITS A GENERAL LIABILITY Y CPP010545600 5/1/2016 5/1/2017 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE f RENTED PREMISESS Ea occurrence $100,000 CLAIMS-MADE 15F]OCCUR MED EXP(Any one person) $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-JECT LOC $ AUTOMOBILE LIABILITY Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Pera ccident $ A UMBRELLA LIAB OCCUR ELP001218200 5/1/2016 5/1/2017 EACH OCCURRENCE $4,000,000 X EXCESS LIAR HCLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY y/N I ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Alderbrook Resort&Spa, Mason County&its employees ATIMA are Additional Insured as respects the 7/3/16, 11/25/16, 12/31/16 Aerial Fireworks Displays located at Alderbrook 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Alderbrook Resort" July2nd, 2015 a� Fireworks Display O r� r k PINK WOIII[O s Ini gwiy�t dte 5/5`2C�1 gat 7.35144b° Ion -123 072526° "elev 13 ft eye alt 31 PART I �® APPLICATION DATE OF APPLICATION - FOR PUBLIC FIREWORKS DISPLAY PERMIT 6/14/16 TO: Governing body of city, town, or county in which display is to be conducted. -APPLICANT NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 1360.790.3409 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E Hwy 106, Union, WA 98592 360.898.5529 PYROTECHNIC OPERATOR _ NAME ADDRESS I LICENSE# Aaron Webb 1417 Evergreen PK Dr #301, Olympia WA 98502 P-04311 NAME OF ASSISTANTS: at least one required) 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 T TIME 7/3/16 10:15pm NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED Not to exceed:(6) Multi-Shot Cakes, (250) 3" Shells, (200) 4" Shells, (87) 5" Shells, (36) 6" Shells MANNER&PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines _ SIGNATUIRE 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 PART II PERMIT PERMIT# DATE: In accordance with the provisions of RCW 70.77 and applicable local ordin ranted to conduct a fireworks display as per the above application. Sthi NAME: i� N (Full name of person,firm,or r °FZ RESTRICTIONS: 0 1. -VA \GPS��d�S ON N��p'GZG'S\dt,s P�PEt�10 Permit not valid without verification of PU- I I rmit) the appropriate State Fireworks License P��\Tt-rnFR( ��RSE1' (�S°�T ao�EFtl 0� LICENSE NUMBER S�P�`I ir'x (Instructions on to side) 3000-420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW (B): Permitee 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 �f State Fire Ma Licensee Signature I 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 Chehalis, WA 98532 Date of Issue: January 28, 2016 License Number: P-04255 Date of Expiration: January 31, 2017 State Fire Ma Licensee Signature Licensee Wall Mount Card '0"'► 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 k_ w Date of Issue:January 28, 2016 Date of Expiration:January 31, 2017 i ' State Fire Ma Licensee Signature � I Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Wholesaler Fireworks License �s-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 f License Number: C-04138 Date of Issue:Janua 28, 2016 Date of Expiration: 31, 2017 �:. ry P January i` i . State Fire Ma Licensee Signature ADDITIONAL INSURED — FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional insured: 1. The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on behalf of the Named Insured; but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. All other terms and conditions of the policy remain unchanged. CG133F(07/95)