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HomeMy WebLinkAboutFIR2018-00049 - FIR Permit / Conditions - 11/7/2018 �x MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line (360)427-7262 Phone: (360)427-9670, ext. 352 Mason County 615 W Alder Street Shelton, WA 98584 All, FIRE PROTECTION PERMIT FIR2018-00049 APPLICANT: WOLVERINE WEST FIREWORKS RECEIVED: 11/7/2018 CONTRACTOR: LICENSE: EXP: ISSUED: 11/7/2018 SITE ADDRESS: 10 E ALDERBROOK DR UNION EXPIRES: 5/7/2019 PARCEL NUMBER: 322335000014 LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58 PROJECT DESCRIPTION: FIREWORKS DISPLAY FOR ALDERBROOK RESORT ON NOVEMBER 23, 2018 @ 5:30 PM ( DOCK AREA OF ALDERBROOK RESORT) GENERAL INFORMATION System Information Type of Use: DIS ' Fire District: 6 Sprinkler Heads: Audible Switches: Pull Stations: Hood& Duct t: Flow Switches: Visual Devices: Door Releases: 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;: p y Total: $250.00 $250.00 FIR2018-00049 Please refer to the following pages for conditions of this permit. Page 1 of 4 •` CASE NOTES FIR2018-00049 Y. CONDITIONS FOR FIR2018-00049 1.) Mason County Fire Marshal's Office approves permits based upon requirements of RCW 70.77.160 for"public display fireworks". Additional permits may be required by agencies where fireworks are displayed on governmental land, private land, or over navigable waterways. It is the responsibility of the licensed permit holder to obtain all additional permits prior to initiating any public display. X 2.) Valid Permit Must be on-site. X OWNER/ BUILDER acknowledges submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below. I declare that I am the owner, owners legal representative, or contractor. I further declare that I am entitled to receive 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 interest regarding this project. The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for review and inspection. This permit/application becomes null &void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. Signature Date OWNER - REPRESENTATIVE - CONTRACTOR Print Name (Circle one to indicate) I Please refer to the followi FIR2018-00049 ng pages for conditions of this permit. Page 2 of 4 P60 coUMaf MASON COUNTY Department of Community Development FIRE PROTECTION SYSTEMS INSPECTION CARD* Mason County, 615 W Alder Street, Shelton, WA 98584 General Questions: (360) 427-9670 ext 352 Inspection Requests: (360) 427-7262 Permit Number FIR2018-00049 Date 11/07/2018 Issued By ^ Project FIREWORKS DISPLAY FOR ALDERBROOK RESORT ON NOVEMBER 23, 2018 @ 5:3 M ( DOCK ARE, Site Address 10 E ALDERBROOK DR UNION Applicant WOLVERINE WEST FIREWORKS Contractor License Number Con. Phone Expiration Date Primary Code 2012 IFC Wet Chem Sprinkler Use DIS Dry Chem Standpipe Hod and Duct -APPROVED PLANS MUST BE ONSITE FOR ALL INSPECTIONS -*THIS STRUCTURE MAY NOT BE USED FOR OCCUPANCY UNTIL ALL REQUIRED FINAL INSPECTIONS ARE APPROVED -DO NOT PROCEED BEYOND EACH STAGE OR COVER WORK UNTIL APPROVAL IS GRANTED -POST THIS CARD IN A CONSPICUOUS LCOATION ON THE FRONT OF THE PREMISES CONVENIENT FOR MAKING REQUIRED ENTRIES. -ALL PERMITS EXPIRE 180 DAYS AFTER PERMIT ISSUANCE OR 180 DAYS AFTER LAST INSPECTION ACTIVITY IS PERFORMED. -OWNER/AGENT IS RESPONSIBLE FOR REQUESTING ALL REQUIRED INSPECTIONS PRIOR TO THE FINAL OCCUPANCY INSPECTIONS -PRIOR TO CALLING FOR FINAL INSPECTION, ALL CONDITIONS OF THE PERMIT MUST BE MET. Public Works Access/Driveway Other Health Dept Septic Well Planning Dept Site Inspection Fire Marshal Fire Apparatus Access Fire Sprinkler Auto Fire Alarm Hood and Duct Other Final Building Dept Building Official: Community Development Designee Concrete Setbacks Slab Footing Perimeter Ret. Wall / Bulkhead Footing Interior Footing Decks/ Porches Foundation Stem Walls Other Rough-In Groundwork Plumbing Plumbing Groundwork Mechanical Other Groundwork Gas Pipe Gas Piping Framing Mechanical Insulation Slab Ceiling Floor Vaulted Ceiling Walls Vapor Barrier - Other Wallboard Nailing Interior Wall Brace Panels Fire walls Other Final Building Manuf. Home Setbacks Setup Concrete Foot/ Runners Final Other MASON COUNTY (360)427-9670 Shelton ext.352 F 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 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 1,5 - =!4 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: Alderbrook Resort & Spa Mailing Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone #: 360.898.2252 Email: cindy.sund@alderbrookresort.com 1 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): License Number: P-04311 Date of Issuance 3/14/18 Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: The Partners Group, Ltd. Insured: Wolverine West, LLC Certified Holder: Alderbrook Resort & Spa Location of Stand/Display: Site Address: 7101 E WA-106, Union, WA 98592 Directions to Site: see attached i Parcel Number: (twelve digit number) - - Fired on Puget Sound Legal Property Owner n/a **Please see reverse side to complete your application** l I ®!'°� APPLICATION DATE OFAPPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT 10/29/18 Governin bod of cit , town, or coun in which dis la is to be conducted. LICANT ADDRESS PHONE olverine West Fireworks PO Box 628 - Chehalis, WA 98532 206.459.0917 SOR ADDRESS PHONE derbrook Resort & Spa 7101 E WA-106 Union WA 98592 360.898.2252 PYROTECHNIC OPERATOR _ NAME ADDRESS LICENSE# Aaron Webb 5030 180th Trail SW, Rochester WA 98579 P-04311 NAME OF ASSISTANTS: (at least one required) - NAME ADDRESS iAGE Herb Harris 2115 9th Ave SW Apt F2, Oly WA 98502 P-04312 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Dock - 7101 E WA-106, Union WA 98592 DATE 11/23/18 TIME 5:30pm NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED [4] 1.2" comets - [20] 3" shells - [10] 4" shells - [20] fountains - [15] cakes MANNER 8 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) The Partners Group ® Bond or certificate of insurance attached ADDRESS El Bond or certificate of insurance on file with State Fire Marshal 11225 SE 6th St., Suite 110 Bond or certificate of insurance shall provide minimum coverage of Bellevue, WA 98004 $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 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 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee Alderbrook Resort 0 o� a t s .. �' Imagery pate: 5/5/201 at t4Z. 32, -1-23.070401 Ela, ft e Ile Washington State Patrol Fire Protection Burea Office of the State Fire Marshal ° � Pyrotechnic OperatorLicense 18-141 Licensee Data Aaron Webb Phone Number: (360) 790-3409 5030 180th Trail Email Address: aaron@wolverinewest.com wolverinewest.com Rochester, WA 98579 Date of Issue: March 14, 2018 License Number: P-04311 Date of Expiration: January 31, 2019 State Fire Marshal Licensee Signature to Licensee Wall Mount Card �oy,,��ct+xy rr�lP Washington State Patrol Fire Protection Bureau . Office of the State Fire Marshal ' �. Pyrotechnic operator License 'Licensee afa „�� x .771,P one umbe : (3 � Aaron Webb " 5030 180th Trail Email Address:aaron@waI rinewes .eom Rochester, WA 98579 Date of Issue: March 14, 2018 :License Number: P-04311 Date of Expiration: January 31, 2019 t.. State Fire Marshal Licensee Signature General Display Employer Portion ;1) Cut along dotted lines to release the four license cards. � `2) All four license cards are individually legal and valid evidence of -------------------------, licensing. ,. 3) All four cards constitute an entire license for a single operator. s 18-1410 } The Licensee must sign all four portions of the license, f s 5) ALL four license cards are legal and valid evidence of licensing. �•� . &) The Licensee must carry either the wallet(landscape)or the License Number: P-04311 ; lanyard card(portrait) Washington State Patrol Fire Protection Bureau itense Number: P-04311 ; Pyrotechnic Operator ; .Pyrotechnic Operator License �� 1 ; Licensing ,t!v 8 Type Washington State Patrol January 31.2019 � Fire Protection Bureau 1 8-1410 f Current and valid Until ; .��• 4 Aaron Webb Pyrotechnic Operator , January 31.2019 Aaron Webb CurrentlVaiid Until Pyrotechnic Operator + « z nsee Signature t i y� a- 00 State Fire Marshal Licensee 5 gnature State Fire Marshal � ' M Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal General Display Fireworks License 18-1190 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 30, 2018 Date of Expiration:January 31, 2019 State Fire Marshal Licensee Signature y i Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Importer Fireworks License 18-1163 r 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 ro License Number: C-04138 Date of Issue:January 30, 2018 Date of Expiration:January 31, 2019 UA State Fire Marshal Licensee Signature Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License 18-1343 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, 2018 License Number: P-04255 Date of Expiration: January 31, 2019 i State Fire Marshal icensee Signature Licensee Wall Mount Card1 1 Al., Ro " CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) `, 6/1/2018 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. ` MPORTANT!Nthe-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 endorsement(s). PRODUCER CONTACT The Partners Group Ltd PHONE FAX 11225 SE 6th St., Suite 110 •425-455-5640 A/c No:425-455-6727 Bellevue WA 98004 nooRes : dessenOtpgrp.com INSURERS AFFORDING COVERAGE NAIC N INSURER A:T.H.E.Insurance Company 12866 INSURED 15539 Wolverine West, LLC INSURERB: Wolverine West Fireworks INSURERC: PO BOX 628 INSURER D: Chehalis WA 98532 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1748877146 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 lltlbfCAT�D. 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. WSR ADDL SUBR POLICY EFF POLICY EXP „. •LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY Y CPP010545602 5/l/2018 5/12019 EACH OCCURRENCE $1.000,000 X COMMERCIAL GENERAL LIABILITY - PREMISES E occurrence $100,000 CLAIMS-MADE I-XI OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $Unlimited GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICYF_j PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT • Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ i, AUTOS AUTOS 1t HIRED AUTOS NON-OWNED PROPERTY DAMAGE $. AUTOS Per accident $ A UMBRELLA LIAB X JOCCUR Y ELP001218202 5/1/2018 5/12019 EACH OCCURRENCE $4,000,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4.000,000 DED I I RETENTION$ $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/NI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if mom space is required) The following are Additional Insured on General Liability as their interest may appear as respects to operations performed by or on behalf of the Named Insured,as required by written contract: Alderbrook Resort&Spa,Mason County&its employees ATIMA are Additional Insured as respects the 7/3/18, 11/23/18,12/31/18 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 •`i; THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Alderbrook Resort&Spa 7101 E State Highway 106 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 i I