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P- N -O 0N a m O S CA O. — (D O 3 6 m cn in _ C � 0 O. m m N °1cn cn(O m co O. m CA N S S a 0 O. cn S n CAN o � O (gyp cA cr O m m O = O a) O �. N O �, O_ W 0 'T1 N 0 0 cc 0 CD 0 w co M 0 Q y I� H i i O Masan County Fireworks Permit Application PO BOX 186 Permit# FIR c 0 dL 426 W Cedar St Shelton WA 98584 Receipt # SX�� (360)427-9670 ext 273 CK # Date Received �o --� -- 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: RANDY NEATHERLIN Mailing Address: PO BOX 445 City: BELFAIR State: WA Zip: 98528 Contact Number 36( 0 )731-384 Sponsor Information Name: NORTH MASON PEE WEES Mailing Address: PO BOX 445 City: BELFAIR State: WA Zip: 98528 Contact Number Washington State Fireworks License Information (Copy Required) License No.: Date of WSPFL-00506 Issue: 02/24/2009 _ ❑ Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: SEE ATTACHED Insured: ......... .. Certified Holder: _ Location of stand1d'isplay/9350 G-` s Address: ALLYN STAND "1 Hi*�3 ALLYN, WA Directions to Site: Parcel Number: - - Legal Description: - Legal Property Owner: * * Please see the reverse side to complete your application I APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWM6502 TO: Governing body of city, town, or county in which DATE OF JAN.02, 2009 fireworks stand will be located. APPLICATION: Applicant Name: Address, City, State: NORTH MASON PEE WEES 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Sponsor(If other than applicant): Address, City, State: RANDY NEATHERLIN 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Location of proposed fireworks stand: [Enclose drawing of stand location] 23861 HWY 3 ALLYN, WA ALLYN STAND Manner and place of storage prior, during, and after sales dates: ON SITE WITH SECURITY State Licensed Fireworks Supplier: American Promotional Events NW 2120 Milwaukee Way, Tacoma, WA 98421 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FIREWO:D.KS STAND PERMIT For The Fireworks Sales Year Of. 2009 (Must be conspicuously displayed at all times while the stand is open to the public) By virtue of having been granted a license by the State of Washington and this permit from MASON COUNTY the local governing authority, the named person, firm or organization is hereby authorized to sell U.N. 0336 I AG Consumer fireworks at the location designated herein between the following date and times: Sales For July 4th Sales For December 31st From: From: To: To: Sponsor: _NORTH MASON PEE WEES Location: ALLYN STAND 2'�ir`rvT3 ALLYN ` N,,�W�A /s/ /s/ �/ � FOR RANDY NEATHERLIN Signature of Official Granting Permit Signature of Applicant Title: Agency: Date: Permit Number: Licensee Name: NORTH MASON PEE WEES License Number:C 3000-420-013 (Rev.2/05) a p a 5 CD Cp Co C o�o � CD 00 oa � a ►� CD oil � o � CD ro O 0 00 � 1-0A� J, rArb eD o r O K A A n o e C y b � � to tea, c CD r ycn (C9 cr 15 � r ro o o (^ y O fD C V y fp rdrtrnr � o d 'b. y Z ! rJ �J a'G �y• '� C co Wa: M n Uj SO A a Q r, b ��.``` ��Y ewe � � �� �' c0 O ~• CD � � n CD a co Z to CERTIFICATE OF INSURANCE ISSUE DATE ACORDTM 02/19/2009 PRODUCER This certificate is issued as a matter of information only and confers no rights MCGRIFF,SEIBELS&WILLIAMS,INC. upon the Certificate Holder. This Certificate does not amend,extend or alter the coverage afforded by the policies below. P.O.Box 10265 Birmingham,AL 35202 800-476-2211 COMPANIES AFFORDING COVERAGE ComApany Columbia Casualty Company INSURED Company American Promotional Events,Inc. B dba TNT Fireworks P.O.Box 1318 Company Florence,AL 35631 C Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement,term or condition of 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,conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE LIMITS OF LIABILITY LT EXPIRATION A GENERAL LIABILITY PCL0223304725 11/01/2008 EACH OCCURRENCE $ 1,000,000 ®Commercial General Liability 11/01/2009 FIRE DAMAGE $ 100,000 ❑Claims Made ®Occurrence MEDICAL EXPENSE $ EXCLUDED ❑Owners'and Contractors'Protection ®$5,000 Deductible Per Doc PERS.AND ADVERTISING INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2.000,000 General Ag regale Limit applies per: PRODUCTS AND COMP.OPER.AGG. $ 2,000,E ❑Policy project ®Location AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ❑Any Automobile BODILY INJURY Per on $ ❑All Owned Automobiles ❑Scheduled Automobiles BODILY INJURY(Per accident) $ ❑Hired Automobiles PROPERTY DAMAGE(Per n $ ❑Non-owned Automobiles COMPREHENSIVE ❑ COLLISION WORKERS'COMPENSATION WC Statutory Limit Other AND EMPLOYERS'LIABILITY EL EACH ACCIDENT $ EL DISEASE(Each employee) $ EL DISEASE(Policy Limit) $ EXCESS LIABILITY EACH OCCURRENCE $ ❑Occurrence ❑Claims Made AGGREGATE $ $ Re:Allyn Stand at 23861 Hwy 3 in Allyn,WA(loc#WWM6502); The Certificate Holder is named as Additional Insured with respect to General Liability as required by written contract subject to policy terms,conditions,and exclusions. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. North Mason Pee Wees Mason County Authorized Representative PO BOX 186 - 426 W Cedar Shelton,WA 98584 Q At el-af �.. , Fa e 1 of 1 Certificate ID# IIXD9A97 February 25, 2009 REF: WWM6502 ***URGENT*** Randy Neatherlin PO Box 445 Belfair, WA 98528 Dear Randy Neatherlin, Enclosed are your City/County permit application, State permit, and insurance. You are required to file with your local authorities as soon as possible. You must have the following items: ® Permit Fee $100.00 (NEEDED) ® Washington State Fireworks License ® Insurance ® Stand Diagram (NEEDED) ® Local Application (finish filling out) • Deadline for filing is June 1 8th Or earlier, LICENSING IS ON A FIRST COME BASIS! Late filing will cause non-issuance of your permit. Should you have any questions or concerns, please feel free to contact me at (253) 922-0800. Thank you for your time and attention to this matter. Have a great season! Sincerely, Brenda Merritt Licensing & Permits Enclosure(s) AMERICAN PROMOTIONAL EVENTS, INC. 2120 MILWAUKEE WAY •TACOMA,WA 98421 TACOMA(253)922-0800 •SEATTLE(253)838-1099 FAX(253)830-2930 www.tnffireworks.com MASON COUNTY Department of Community Development FIRE PROTECTION SYSTEMS INSPECTION CARD* PO BOX 186, 426 W Cedar ST, Shelton WA 98584 Irflo General Questions: (360) 427-9670 ext 352 Inspection Requests: (360) 427-7262 Permit Number FIR2009-00038 Date 06/26/2009 Issued By Project FIREWORKS STAND Site Address 18350 E STATE ROUTE 3 ALLYN Applicant NORTH MASON PEE WEE'S Contractor License Number Con. Phone Expiration Date Primary Code 2006 IFC Wet Chem N Sprinkler N Use STND Dry Chem N Standpipe N Hod and Duct N 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 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 APPROVED PLANS MUST BE ONSITE FOR ALL INSPECTIONS *THIS STRUCTURE MAY NOT BE USED FOR OCCUPANCY UNTTL ALL APPLICABLE FINAL INSPECTIONS ARE COMPLETED DO NOT PROCEED BEYOND EACH STAGE OR COVER WORK UNTIL APPROVALS ARE GIVEN. POST THIS CARD IN A CONSPICUOUS PLACE ON THE FRONT OF THE PREMISES CONVENIENT FOR MAWNG REQUIRED ENTRIES. ALL PERMITS EXPIRE 180 DAYS AFTER PERMIT ISSUANCE OR 180 DAYS AFTER LAST INSPECTION ACTIVITY IS PERFORMED. OWNER/AGENT IS RESPONSIBLE FOR CALLING FOR ALL INSPECTIONS PRIOR TO CALLING FOR FINAL INSPECTION,ALL CONDITIONS OF THE PERMIT MUST BE MET. 77 CONCRETE MECHANICAL MANUFACTURED HOME r� p Footings I Setbacks Date By Ribbons —1 Gas Piping = C interior Date By Interior-Date By Date By 3 OC Exterior Date By Exterior-Date By Setup _ N Point toad/Isolated Footings INSULATION BG t BLAB INSULATION Data By z Date By Data By FIRE DEPARTMENT Foundation Walls Floors Date By m Date By Date By DECKS FRAMING waits Date By m Date By Data By PROPANE TANKS N PLUMBING vault Date By Date By OTHER. Groundwork Attic . Date By Data By Type- DRYWALL By o.W.V DRYWALL Type: Int Brace Wall Date B T Date By Y I Date By FINAL INSPECTION N Water true Fin Seperation O Date By Date By Date By b o Pass or Request I nspect. c Type of Insp. Fain Date Date D y Comments ao R 0 N I to L 3 0 rn i