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HomeMy WebLinkAboutFIR2012-00017 - FIR Permit / Conditions - 7/3/2012 R MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 ` Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670, ext. 352 Shelton, WA 98584 i� FIRE PROTECTION PERMIT FIR2012-00017 APPLICANT: ALDERBROOK RESORT RECEIVED: 6/18/2012 CONTRACTOR: LICENSE: EXP: ISSUED: 7/3/2012 SITE ADDRESS: 10 E L ERBROOK DR UNION EXPIRES: 1/3/2013 PARCEL NUMBER: 32233 Coo14 LEGAL DESCRIPTION: SUN BEACH PCL 1 OF BLA#04-58 PROJECT DESCRIPTION: FIREWORKS DISPLAY 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?: N Dry Chemical?: N Pressure Switches:: Smoke Detectors: Duct Detectors: Wet Chemical?: N Zones: Heat Detectors: Sprinkler?: N Standpipe?: N 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?:N Third Floor;: Total: $250.00 $250.00 FIR2012-00017 Please refer to the following pages for conditions of this permit. Page 1 of 3 CASE NOTES FIR2012-00017 CONDITIONS FOR FIR2012-00017 1.) A 70 foot set back per 1 inch of mortar diameter is required. Spectators, spectators parking areas, and dwellings, buildings or structures shall not be located within the Display area. Exception: This provision shall not apply to unoccppied dwellings, buildings and structures with the approval of the building owner and the fire code offical. It shall be the responsiblity of the display holder to obtain approval from all property owners prior to the fireworks display. X Per section 3308.6 of the 2009 International Fire code. Mortars for firing fireworks shells shall be installed in accordance with NFPA 1123 and shall be positioned so that shells are propelled away from spectators and over the fall out area. Under no circumstances shall mortars be angled toward the spectators viewing area. Prior to placement, mortars shall be inspected for defects, such as dents, bent ends, damaged interiors and damaged plugs. Defective mortars shall not be used. X — -. Post display inspection After the fireworks display, the firing crew shall conduct an inspection of the fall out area for the purpose of locating unexploded aerial shells of live components. This inspectin shall be conducted before the public access to the site shall be allowed. Where fireworks are displayed at night and it is not possible to inspect the site thorughly, the operator or designated assistant shall inspect the entire site at first light. A report identifying any shells that fail to ignite in, or discharge from, a mortar or fail to function over the fallout area or otherwise malfuction, shall be filed with the fire code offical. There shall be a minimum of two approved , water filled pressurized fire extinguishers. This permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended for a period of 180 days at any time after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied. Proof of continuation of work is by means of a progress inspection.The owner or the agent on the owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure for review and ins pection. OWNER OR AGENT: DATE: I 2 FIR2012-00017 Please refer to the following pages for conditions of this permit. Page 2 of 3 - I v 55 CONCRETE MECHANICAL MANUFACTURED HOME r, Np Date By m Footings!Setbacks Gas Piping Ribbons X N interior Date By interior•Date By Date By CExWior Date By Exterior-Date By Setup 0 V Point Load/Isolated Footings INSULATION Date By X BG I SLAB INSULATION Date By Data By FIRE DEPARTMENT _ X Foundation Walls Floors Date By Cn O Date By Data By' DECKS X FRAMING Wars Date By Date Ry Dat` ..__ _...� By PROPANE TANKS PLUMBING vault mate By -- Date By OTHER Groundwork Attic Date By Type' Date B y Oats By D.W.v DRYWALL Type: Int Brace Wall pate By Date By _ X Date By FINAL INSPECTION N to O Water Line Fire Separation Date By Date By Date By N O o Pass or Request I nspect. o Type of Insp. Fail Date Date Done By i Comments y 0 o p ` _ Z—/L 7 3-/Z d N M O n O 3 a 0 3 fA O 3 N N M N (fl (D W O W .... -- Mason County Fireworks Permit Application PO BOX 186 426 W Cedar St Permit# FIR.53laj'—f Shelton WA 98584 • (360) 427-9670 ext 273 Receipt # CK # Date Received A Permit for the 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 Name: Alderbrook Spa&Resort Mailing Address: 1210 Saskatoon UN SE City: Olymipa State: wA Zip: 98513 Contact Number (253 ) 224-0997 Sponsor Information Name: Alderbrook Spa and Resort Mailing Address: 7101 WA-106 City: Union _ State: wa Zip: 98592 Contact Numberg�gc�g_55? _ .___ Washington State Fireworks License Information (Copy Requiredj License No.: Date of P-04311 Issue: 01/01/2012 ✓❑ Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: Combined Specialties International,inc. i Insured: Orion Pyrotechnics Certified Holder: Alderbrook Spa& Resort _ Location of stand/display Address: 496, Union, WA 98592 0 A 1e6 rbym LZY' Directions to Site: See Attachment Parcel Number: ,'g�7 � - es Legal Description: Legal Property Owner: * * Please see the reverse side to complete your application APPLICATION PART I 06-02-2012 N FOR PUBLIC FIREWORKS DISPLAY PERMIT TO: Governipa body of city,town,or county in which display is to be conducted. :APPLICANTS non Pyrotecnics askatoon LN SE Olympia,WA 98513 0-3409 JXrcPe"rb'r'o'ok Spa and Resort 17101 WA-106,Union WA 98592 360-898-5529 PYRO TEC HN1C 4PE5AT PR - Baron Webb 712 36t Ave Olympia,WA 98506 P-04311 ane Chancey Wilkins 3805 College ST.SE Olympia,WA 98503 33 VNryIC :EXACT C ATiQN Of ;RPPOSED IXSPLAY UN 4leer�rook Spa and Resort 7101 WA-106,Union WA 98592 vr.ram.. 07-03-2012 10:00pm NUMBER AND., {NDS OF FIREWO `. O BE PAYED (385)3"Aerial Shells (39)6"Aerial Shells (168)4"Aerial Shells (4)8"Aerial Shell (79)5"Aerial Shells rmltiple-shot cake _ (912"Roman candies —_ MA IsR 48 CE ar"`STORAG `PRIOR Ta l$PILAY.;(Siibje t#o app eiri of f4 ova! #re Auth+ 5► r tlu-storage re t SI PPLICANT FINANOIAt t2ESPONSIB#LJTY` _ - _ I BONDING iNSU AN 'c COMPANY (Mark One) Combined Specalties Inc. 0 Bond or certificate of insurance attached © Bond or certificate of insurance on file with State Fire Marshal 205 San Mario Drive,Suite 5 Bond or certificate of insurance shall provide minimum coverage of $50,000/$1,000,000 bodily injury liability for each person and event, Navato,California 94945 respectively,and$26,000 property damage PART a PERMIT PERMIT# F DATE: In accordance with the provisions of RCW 70.77 and applicable local ordinances, this peel.it is granted to conduct a fireworks NAME: RESTRICTIONS: Permit not valid without verification of (Sionahira of Official arantina oermitl the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee Alderbrook Fireworks Display ` July 301 201Z 410. Traffic Fiore.. t.lap Satellite Earth A211111111111111 700' Diameter We '" Secured Permiter Barge Location dIr } rT �t r _f tnn a„ Washington hotel- t:asttivtytu+i° u ti,e'ti'Ioteis ir;yjashmyton ::est:fates :.i;nE, ,uaier..eec one _..—.__._._......._. _m�...—_ Intenet DOU)e-c.-_k to.nan;e se it}se bgs Certificate of Insurance 113322 Issue Date: 6/1/2012 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF Deborah Merlino INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT Combined Specialties International, Inc. AMEND,EXTEND OR LATER THE COVERAGE AFFORDED 205 San Marin Drive, Suite 5 BY THE POLICIES BELOW. Novato, California 94945 INSURERS AFFORDING COVERAGE INSURED Pyrotecture, LLC INSURER A: Underwriters, Lloyd's London DBA: Orion Pyrotechnics INSURER B: 11210 Saskatoon Lane SE INSURER C: Olympia, WA 98513 INSURER D: COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE PERIOD INDICATED.NOTWITHSTANDING ANY RFOUIREMENT,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 HERIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INCLUDING,BUT NOT LIMITED TO THOSE FOLLOWING:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,ADDITIONAL CONDITIONS AND EXCLUSIONS:1)THE - INSURANCE EVIDENCED BY THIS CERTIFICATE IS LIABILITY INSURANCE ONLY,IT IS NOT A BOND OR ANY FORM OF SURETY AGAINST WHICH SOMEONE OTHER THAN"INSURED"MAY ASSERT A CLAIM OR BRING ANY ACTION, SUBJECT TO POLICY TERMS,CONDITIONS,DEFINITIONS AND EXCLUSIONS THE INSURANCE ONLY INDEMNIFIES AN INSURED AGAINST CERTAIN LEGAL LIABILITY.2)THE INSURANCE DOES NOT COVER CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE OF THE NAMED INSURED'S SHOOTER(S)ASSISTANT(S)OR ANY OTHER PERSON(S)INCLUDING ANY VOLUNTEER(S)PARTICIPATING IN ANY WAY IN ANY DISPLAY OR SPECIAL EFFECT PERFORMED OR EXECUTED BY THE NAMED INSURED.3)COVERAGE DOES NOT APPLY TO CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE ARISING OUT OF THE INSURED'S FAILURE TO FOLLOW NFPA OR OTHER APPLICABLE REQUIREMENTS,LAWS OR RECOMMENDATIONS,INCLUDING THOSE RELATING TO POST DISPLAY OR SPECIAL EFFECT SEARCHES OR CLEAN UP. I CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(DD/MM/YY) DATE(DD/MM/YY) A GENERAL LIABILITY CSI-844650-12 5/15/2012 5/15/2013 EACH ACCIDENT $1,000,000 CLAIMS MADE MEDICAL EXP(any one person) $5,000 FIRE LEGAL LIABILITY $50,000 GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OPS AGG $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Each accident) ANY AUTO ANY OWNED AUTO SCHEDULED AUTOS BODILY INJURY(Per Person) HIRED AUTOS BODILY INJURY(Per Accident) NON-OWNED AUTOS PROPERTY DAMAGE (Per person) EXCESS LIABILITY EACH ACCIDENT FOLLOWING FORM AGGREGATE WORKERS COMPENSATION WC STATUTORY OTHER LIMITS AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT E.L.DISEASE-EA EMPOYER E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Alderbrook Spa & Resort is Additional Insured as respects the July 3, 2012 (RD: TBD) 1.3G Fireworks Display at Alderbrook Spa & Resort, 7101 WA-106, Union, WA CERTIFICATE HOLDER SHOULDLATION ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO Alderbrook Spa & Resort THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IWOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. 7101 WA-106 Union, WA 98592 uv - �� Washington State Patrol a look,. Fire Protection Bureau 1 3 �775 Office Of The State Fire Marshal P A yro aroii 'W ebb technic Operator License Number: I -0 I I Ty Pyrotechnic Operator Pe oi License: Expi,r,ation Date : Januai-y 31 , 2013 State Fire Mar L,`, vmature Licensee ign .tore Mason County Fireworks Permit Application PO BOX 186 426 W Cedar St Permit# FIR Shelton WA 98584 (360)427-9670 ext 273 Receipt # ,/ CK # �t 12 `.._._ Date Received A Permit for the 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 _ Name: Orion Pyrotechnics Mailing Address: 11210 Saskatoon LN SE City: Olymipa State: WA Zip: 98513 Contact Number (253 ) 224-0997 Sponsor Information Name: Chad Hauler Mailing Address: 2601 70Th Ave. W City: University Place _ State: WA Zip: 98466 Contact Number .1 )377-3039 Washington State Fireworks License Information (Copy Required] License No.: Date of P-04313 Issue: 3/15/2012 F, Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: Combined specalties inc, Insured: Orion Pyrotechnics Certified Holder: Orion Pyrotechnics ^_ Location of stand/display Address: Mason Lake, Shelton Washington Directions to Site: Attached Parcel Number: 2 W 0jq - - Legal Description: lake _ CJ� — 11— Legal Property Owner: * * Please see the reverse side to complete your application ©off APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT TO: Governing_body of city,town, or county in which display is to be conducted. . APPLICANT Nm6 Pyrotechnics RMgaskatoon Ln SE, Olympia,WA 98513 396`f91-5055 0?Efflh Ave W., University Place, WA 98466 M-57-3039 PYRUTEOHNIC OPERATOR._ TaAc'6 B. Johnson 1`?Rf52orris RD SE Yelm, WA 98597 NAME o�McClureSlSTaNT� t�t �8���akes Tocama I_ -WA 98406 48E 1 4 1 9.9 acfc e 9th Ringquist AVE SE Yelm WA 98597 � E EXAG ATI N OPOSED DISPLAY -- I ason�-Nake Union Washington O Mh/2012 TV-5opm NUMBER AND.KWD6 OF FIREWOR#€9-TT0 BE DISP_LAXED (366)4"Aerial Shell (12)2" Exhibition candles (105)6"Aerial Shell 11Aerial (8) 10"Aerial Shell (11UU)3"Aerial Sb&ll- -- MANNER&_P ii" :I*(lF STURAO PRIOR TO DISPLAY ub'eci to approval of Lora)Flti-Authpr�) F ; Ito delivered to display si te day Of S!low. SIG NT FINANCIAL RIESPONSIBILITY" BONDINQ OR INSUBANCE COMPANY (Mark One) Combined Specalties, Inc E] Bond or certificate of insurance attached ADDRESSQ Bond or certificate of insurance on file Mth State Fire Marshal 205 San Marin Drive, Suite 5 Bond or certificate of insurance shall provide mininTum coverage of Navato, California 94945 $50,0001$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II � P <ERMIT PERMIT# DATE. In accordance with the provisions of RCW 70.77 and applicable local ordinances, this pit is granted to conduct a fireworks NAME: RESTRICTIONS: Permit not valid without verification of (SinnnturP of Official orantino oermit) 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 Certificate of Insurance 113319 Issue Date: 6/1/2012 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF Deborah Merlln0 INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT Combined Specialties International, Inc. AMEND,EXTEND OR LATER THE COVERAGE AFFORDED 205 San Marin Drive, Suite 5 BY THE POLICIES BELOW. Novato, California 94945 INSURERS AFFORDING COVERAGE INSURED Pyrotecture, LLC INSURER A: Underwriters, Lloyd's London DBA: Orion Pyrotechnics INSURER B: 11210 Saskatoon Lane SE INSURER C: Olympia, WA 98513 INSURER D: COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE 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 HERIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INCLUDING,BUT NOT LIMITED TO THOSE FOLLOWING:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.ADDITIONAL CONDITIONS AND EXCLUSIONS:T)THE INSURANCE EVIDENCED BY THIS CERTIFICATE IS LIABILITY INSURANCE ONLY,IT IS NOT A BOI:O OR ANY FORM OF SURETY AGAINST WHICH SOMEONE OTHER THAM'INSURE.D'MAY ASSERT A CLAIM OR BRING ANY ACTION. SUBJECT TO POLICY TERMS,CONDITIONS,DEFINITIONS AND EXCLUSIONS THE INSURANCE ONLY INDEMNIFIES AN INSURED AGAINST CERTAIN LEGAL LIABILITY.2)THE INSURANCE DOES NOT COVER CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE OF THE NAMED INSURED's SHOOTER(S)ASSISTANT(S)OR ANY OTHER PERSON(S)INCLUDING ANY VOLUNTEER(S)PARTICIPATING IN ANY WAY IN ANY DISPLAY OR SPECIAL EFFECT PERFORMED OR EXECUTED BY THE NAMED INSURED.3)COVERAGE DOES NOT APPLY TO CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE ARISING OUT OF THE INSURED'S FAILURE TO FOLLOW NFPA OR OTHER APPLICABLE REQUIREMENTS,LAWS OR RECOMMENDATIONS,INCLUDING THOSE RELATING TO POST DISPLAY OR SPECIAL EFFECT SEARCHES OR CLEAN UP. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(DD/MM/YY) DATE(DD/MM/YY) A GENERAL LIABILITY CSI-844650-12 5/15/2012 5/15/2013 EACH ACCIDENT $1,000,000 CLAIMS MADE MEDICAL EXP(any one person) $5,000 FIRE LEGAL LIABILITY $50,000 GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/OPSAGG $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Each accident) ANY AUTO ANY OWNED AUTO SCHEDULED AUTOS BODILY INJURY(Per Person) HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per Accident) PROPERTY DAMAGE (Per person) EXCESS LIABILITY EACH ACCIDENT FOLLOWING FORM AGGREGATE WORKERS COMPENSATION WC STATUTORY OTHER LIMITS AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT E.L.DISEASE-EA EMPOYER FE.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Chad Hauer as sponsor is Additional Insured as respects the July 3, 2012 (RD: TBD) 1.3G Fireworks Display at Mason Lake, Mason County, Shelton, WA CERTIFICATE HOLDER SHOULDLATION ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 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 Chad Hauer THE COMPANY,ITS AGENTS OR REPRESENTATIVES. 2601 70th Avenue West University Place, WA 98466 -— — — AUTHORIZED REPRESENTATIVE ---- Washington State Patrol Fare Protection Bureau Office Of The State Fire Marshal f Washington State Fireworks License Pyrotechnic Operator License Pyrotechnic Operator: Jacob B. Johnson Licensee Location: 11547 Morris Road Southeast Detach this wallet card and catty with you for Yelrn,WA 98597 verification of certification. Washington State Patrol r Phone Number: (253)244-0997 Fire Protection Bureau 1 3679 Office Of The State Fire Marshal Pyrotechnic Operator Jacob-B.J.ohnson Date of Issue Expiration Date License Number License Number: P-04313.Type of License: Pyrotechnic Operator March 15,2012 January 31,2013 P-04313 Expiration Date: January 31,2013 1 3000-420-012(R 9/05) State Fire arsh'al i nature Licensee Signature a • I