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Home My WebLink AboutFireworks - FIR Application - 7/19/2016 913 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 �t of if Ma ® w f `�f1, 426 West Cedar Street fie A 98584 www.co.mason.wa.us Pg0 6� N • ER��pso s FIR20 - Ole o s ` s�E EG�\d soNQ��p irevvorks Permit application PLC PP�o�aSS�oH act NSp�CI tN�s Pp� P�%° of ro fo--0Svy, lications Hill not be accepted g ublic display of fireworks is required. A completed �, uired documentation and fees shall be submitted for Fire Marshal r N q ermit will be issued upon satisfactory, site inspection by the Fire Marshal. plicant Information: Owner: ra + 4�= �+ 4= Mailing Ad ress: >Z � lCt--3 Cite: G tate:�Zip: L c Phone #• 3(co - -Iq t - o S Email: ro 12 Sponsor information: Name: t .itb; lY1A� �n Address: l ! amity: a t QY State: i, Zip: at�ta- Phone 4: Email: Washington State Fireworks License Informa l,(Copy Required): License Number: Q_ ('° 4j L+C Date of Issuance L, /i) )(Pyrotechnic Operator License tJ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: to S f411*-,, c� Insured: F;, Certifier!Hold Location of StmW/Disnlav: Site Address:_ 1 t7 Directions to Site: a - Parcel Number: (twelve digit number) - - Legal Property Owner **Please see reverse side to complete your aMARSHAL I i ill , 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— V-1eV-k 4 a y-,e- ark- ,J MUST MEET ALL CURRENT WASHINGTON STATE CODES MUST MEET ALL CURRENT WASHINGTON STATE CODES Applicants Affidavit I certify that the information provided herein is accurate and that compliance with all Co ty, State and Federal laws pertaining to the sales or discharge of fireworks shall be main i Signene �U Date r _ gar CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YY) 7/29/13 PRODUCER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER 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 A: ADMIRAL INSURANCE COMPANY Pyro&Fire FX,LLC INSURER B: P.O.Box 193 INSURER C: Gig Harbor,WA 98335 INSURER°: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN M AY H ANT BEEN REDUCED BY PAID CLAIMS. INSR. POLICY POLICY EXPIRATION LTIL TYPE OF INSURANCE POLICY NUMBER EFFECTIVE DATE LIMITS DATE GENERAL LIABI.rI'Y EACH OCCURRENCE $5.000,000 —K_COMMERCIAI.GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 50,000 A _2L_OCCURRENCE_CLAIMS MADE CA000003209-23-1110 6/21/13 4/17/14 '¢D EXP(Any one pawn) $ NONE PERSONAL&ADV INJURY $5,000,000 GENERAL AGGREGATE $6,000,000 G1N'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $Included _X_POLICY_PROJECT_LAIC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ _ALL OWNED AUTOS NOT COVERED BODILY INJURY _SCHEDULED AUTOS (Per person) _HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) _ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY NOT COVERED EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE NOT COVERED DEDUCTIBLE RETENTION S WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY NOT COVERED OTHER A Stop Gap Liability CA000003209-23-1110 4/17/)3 4/17/14 $500,000 DESCRIPTION OF OPERATIONS/IACATIONSNEHICLFS/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. CERTIFICATE HOLDER Mason County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 426 West Cedar Street THE POLICY PROVISIONS. PO Box 279 Shelton,WA 98584 FI' Ac-' k1'1'IIORIZEDREPRESENTATIYE .4..1.Stringier Washington State Patrol Fire Protection Bureau � Office of the State Fire Marshal General Display Fireworks License 1 -1184 Licensee Data Operational Data Pyre & Fire FX, L.L.C. In State Agent: Richard Olsen P.O. Sox 193 Phone Number: (253) 307-5118 Gig Harbor, WA 98335 Email Address: pyro2940@aol.com License Number: C-04262 Date of Issue:January 14, 2016 Date of Expiration:January 31,,2017 State Fire March, Licensee Signature FARE MPS Washington State Patrol Fire Protection Bureau office of the State Fire Marshal Pyrotechnic Operator License 16-1232 f , L.icen _seeData Pickard J. Olsen Phone Number: (000) OOCI-OQQO Post Office Box 193 Email Address: pyrra2940@aol.com Gig Harbor, WA 98335 Date of Issue: January 19, 2016 � License Number: P-02940 Date of Expiration: January 31, 2017 State Fire Mar Licensee Signature Licensee W-ait Mount Carat — —.....-_.,————————__—_ — ' Washington Mate Patrol Fire Prc�tectic�n Bureau Office of the Mate Fire Pyrotechnic Operator i Licensee Data .. Luke Hemphill Phone Nurnberg (000) 000-0000 13514 185TH CT E Email Address: lhemphil151 @9mail.com � , Bonney Lake, WA 98391 Date of Issue. January 20, 2015 ., License Number- P-04426 [date of Expiration January 31 , 2017 Mv _ r r � State Fire Mar al� Licensee Signature — — — �.. ...._. _._.� — _.._ �... ..W... ....... ._._. — _... .ar.... .w... — ...�o� � �'��' ��r�t�Ic��gar r�'��ti�ar�� 4. _a� � _r_ _� � _ � �.. �,. ._ — _... .._., ._... ._. cI� � License umber: P-04311 Pyrotechnic Operator License Washington state Patrol 10 1 5)OP Fire Protection Bureau January 31 , 2020 Aaron Webb Current/Valid lentil Pyrotechnic Operator Stale Fire Marshal Licensee'- ignaWre DDO-420-043 (10/18) Washington State Patrol Fire Protection Bureau --� 20f 2G Office of the State Fire Marshal U� General Display Fireworks License FrAR3NAVS 6<� Licensee Data Operational Data Wolverine West, LLC In State Agent: Rodney F. Hash Post Office Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@woIverinewest.com License Number: C-04138 Date of Issue:January 16, 2019 Date of Expiration:January 31, 2020 Z40F "2w 4 -t-:�L State Fire Marshal Licen e Signature 3000-420-041(10118) Washington State Patrol Fire Protection Bureau c 9 .� �f f Office of the State Fire Marshal Importer Fireworks License f�ty�RiNAt"S OS� Licensee Data Operational Data Wolverine West, LLC In State Agent: Rodney F. Hash Post Office Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 16, 2019 Date of Expiration:January 31, 2020 -e-�� 'j- . "W"t, State Fire Marshal Lice ee Signature 3000-420-041(10/18) ��giNGPON gr�,r� Washington State Patrol Fire Protection Bureau c -) Office of the State Fire Marshal Pyrotechnic Operator License 44 ke'N4R9 NAL'S p4`' 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 30, 2019 License Number: P-04255 Date of Expiration: January 31, 2020 State Fire Marshal Licensee Signature