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HomeMy WebLinkAboutFIR2009-00031 Final - FIR Permit / Conditions - 7/2/2009 � V � CD m m o q r- k@ / 9 .CD \ / � k� I ¥ g \ � > � � 0 = 2 (D � CL 22 -1a) m � > mG \ 2 ® § 3q O0 �m > m . %& E # � ) ¢ m �\ 00 IP, 22222@v < JU / R > zkC � k $ � 0 Q � qqm > g C @ 90 � 22 . # • z � � m * Z � « 0 c w 0) 0 I mX2 * � > O -0m b 'n & C § m 5- c X 0 f ca *k q O / 8 � � � E � c § �7 c m g � E ƒ o k a 2 c ¢ f ° Rm 2 : - k M $ O 2 0 0 9 m 2 ma 2 g m =r q A 0 p . Z ; n r tX M 2 - 3 § z E ƒ I3 ƒ ® 2 k0 / a 3 oo - @ (b (Do kk f0 § � < n m ° ° Q E & ] § § . E -n m m 3 CA m w 0 � U 2 m 2 c < CD mmm � R � oO @99 3 � ® § 2 © � -n 2 $ � m � � dU k \ E ■ g 000 q22 N ƒ E i k q R co p § CD c 2 K I 2k 0 9 O « m % � 0 � fd � . o y � os �. 3 -. o (D X cn 0 o � � s8 o R' �S CL9 m O y n H Y n N (D C .y' O C1 G % N O 3 j O —. O 5. CD O 0— CD 0 o D cn _. o � : r N y Z (D UT) cr co tg S m O m rt y --I V1 > > O O fD CL G ii m @ :E• Oo g 8 m o ° ? 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In V Int.Brace wall Date By Date By Date By X FINAL INSPECTION N 0 wafter Line Fin Seperation O Date By Date By Data By o Pass or Request Inspect. c Type of Insp. Fall Date Date D By Comments w 0 U! 1 5 W 3 r► i i w 0 a, ACORQ. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 3 9 2009 PRODUCER Phone: 440-248-4711 Fax: 440-248-5406 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton-Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cleveland OH 44139 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Lexington Insurance Co Entertainment Fireworks, Inc. INSURER B:Granite State Insurance Co. 23809 P. 0. Box 7160 Olympia WA 98507-7160 INSURERC:AXIS Surplus Ins Company INSURER D: 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR INSR TYPE OF INSURANCE A GENERAL LIABILITY 1619 9 3 3-01 2/15/2 0 0 9 2/15/2 010 EACH OCCURRENCE $ j 0 0 0 0 0 0 COMMERCIAL GENERAL LIABILITY DAMAGE O RENTED X PREMISES Ea occurence $5 0 000 CLAIMS MADE i] OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,0 0 0,0 0 0 GENERAL AGGREGATE $2 0 0 0, 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,0 0 0 0 0 POLICY X JE LOC - $ PRO- AUTOMOBILE LIABILITY CA6 2 6 5 8 5 2 6 2/15/2 009 2/15/2 010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,0 0 0,0 0 0 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: qGG $ C EXCESS/UMBRELLA LIABILITY EAU7 0 5 9 7 8 2/15/2 0 0 9 2/15/2 010 EACH OCCURRENCE $1 0 0 0 0 0 0 X I OCCUR CLAIMS MADE AGGREGATE $1 0 0 0 0 0 0 { $ DEDUCTIBLE $ RETENTION $ $ TH- WORKERS COMPENSATION AND WC STATUS O EMPLOYERS'LIABILITY TORYLIMI7S ERR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ _ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Date of Display: July 2, 2009. Location: From Barge in front of Alderbrook Resort on Hood Canal. Addl. Insureds: ' Alderbrook Resort & Spa, Gold Coast Oyster LLC (Scott Grout - Barge Owner) , Mason County, their officers, agents, and employees when acting in their official capacity as such. s 4 r. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER Alderbrook Resort & Spa WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 10 E. Alderbrook Drive CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Union WA 98592 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108) ©ACORD CORPORATION 1988 ) IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. i i ill ACORD 25(2001/08) ooM.®® APPLICATION APP Teo ; PARtL DATET I FOR PUBLIC FIREWORKS DISPLAY PERMIT V TO: Governing, body of ci ,town, or county in which display is to be conducted. am, a s ry v NAME ADDRESS PHONE Entertainment Fireworks, Inc. PO Box 7160 Olympia WA 98507-7160 360-352-8911 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 10 East Alderbrook Dr. , Union WA 98592 360-898-5529 to . NAME ADDRESS LICENSE# 41+i0 Jay Himlie 2365 SE Arcadia Rd, Shelton WA 98534 P-04117 NAME ADDRESS AGE Brianna Himlie 606 Lilly Rd NE, Olympia WA 98506 26 NAME ADDRESS AGE wll VF- V Pi Y LOCATION loading @ property adjacent to5091E SR 106 Union WA 98592 off a bare at the end of the pier dock area @ Alderbrook Resort & Spa DATE TIME Julv 2, 2009 Dark A rox 10:15 PM 2.0" Salutes - 10, 2.0" & 3.0" Comets - 6, 1.5" Roman Candles - 2, 1.0" Multi-shot Cake Device - 1 2.5" Aerial - 25 3.0" Aerial - 102 4.0" Aerial - 82 N PtACE OF$VR ► E ©iSPLAY' eet €# " 1©f Go i FireAA'itlltoft) Delivered to site day of display. SIGNATURE OF APPLICANT _ BONDING OR INSURANCE COMPANY (Mark One) Britton Gallagher & Associates U Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal Bond or certificate of insurance shall provide minimum coverage of 6240 SOM Center Rd. Cleveland OH 44139 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART 11 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: f/4y 11::1 (Full name of person,firm,or oration granted permit) RESTRICTIONS: Permit not valid without verification of nature of g n ing p it?' the appropriate State Fireworks License � NF (Title) LICENSE NUMBER: C-04085 (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee Masonnt Fireworks Permit .Application PO BOX 186 Permit # FIR ��� --� � 426 W Cedar St 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: Entertainment FirevorkA, Tnc-_ Mailing Address: Po Box 7160 City: 01 y,,,z;a State: WA Zip: Contact Number (360 ) 352-8911 Sponsor Information Name: Alderbrook Resort & Spa Mailing Address: 1() F._ Al c9erbrook nr City: Union State: WA Zip: 98r:g2 _ Contact Number ( 360 )898-5527 Washington State Fireworks License Information (copy(Required) j License NO.: C-04085 Entertinanment FireworksDate of 2-26-09 P-04117 ,lay Himlip Issue: Pyrotechnic Operator License El Fire,.wrks Stand License { I Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: See Attached Insured: Certified Holder: Location of stand/display Address: 7101 E. State Route 106 Union - Alderb ook Resort & spa r Directions to Site: Take Hwy- 16 West to Gorst, then go South on JHW-y. 3 to Belfai South of Belfair turn right on Hwy 106 & Go 15 miles to Alderbrock Parcel Number: - - 322335000014 Legal Description: Sunny Beach Tr 8-11 EX and Tax 895 See SP # 1664 Legal Property Owner: * * 'lease see the reverse side to complete your application The f011OWiD2 Pertinent information MUST be provided on the site diagram belovy Locations and Setback distances from the back, sides and front of retail sales stands or d esignated display areas to: • Property Lines • Fire Hydrants • Buildings • Parking • Combustibles • Public Roads aind Right of Ways • Fire Lanes • Private Roads and Right of Ways • Trees/ Brush • Landmarks • Utilities and Gas • Mortar separation distance • Designated landing area 1 I i i H Applicants Affidavit I certify that the information praviided herein is accurate and that compliance: with all County, State and Federal laws pertaining to the sales or discharge of fireworks shall be maintained. Signed Date — -_FOR__ OFFICIAL, USE✓ ONLY BELOW THIS LANE Accepted By: Date: 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 FIR2009-00031 Date 06/22/2009 Issued By Project JULY 4TH DISPLAY AT ALDERBROOK/UNION Site Address 7101 E STATE ROUTE 106 UNION Applicant ENTERTAINMENT FIREWORKS, INC Contractor License Number Con. Phone Expiration Date Primary Code 2006 IFC Wet Chem N Sprinkler N Use DIS 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 PLANT MUST BE ON SITE FOR ALL INSPECTIONS "THIS STRUCTURE MAY NOT BE USED FOR OCCUPANCY UNITL ALL APPLI CABLE 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 MAIQNG 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. MR N CO ld Q? w. � aoi Pon*. > , cx a o c O A`Zwz.= ' � d o d Cd or- 1� .L a � a W 00 Cd I z vi vi A � cj a •'� •� 5 p 3 � 3ppo p 00 cc es 1.99 Cd o � POO cd '� M cc co ++ C It .4� cd p haw � �aEcn Co G4cuw, y cc CC . LO V1 3w EA rA y N •p" cd ji I I