HomeMy WebLinkAboutFIR2010-00015 Fireworks - FIR Permit / Conditions - 6/1/2010 1 1
Mason County
Fireworks Permit Application
PO BOX 186 426 W Cedar St Permit# FiRo 5
Shelton WA 9&W Receipt #
(360)427-9670 ext 273
-�55 83o-2'�>0 CK #
Data Received rt�p to
A Permit for the AaW Sales or Public display of fireworks is required. A c orripleted
application with required documentation acid fees shall be submitted for Fire Marshal
review. A permit will be issued upon satisfactory site inspection by the Fire Marshal.
Applicant Information
Nape: TYSON DEVRIES
Mailing Address: 23001 NE STATE RT 3
City: BELFAIR State: WA Zip. 98528
Contact Number (360) 277-3778
Sponsor Information
Name: BELFAIR ASSEMBLY OF GOD
Mailing Address: 23001 NE STATE RT 3
City: BELFAIR State: WA_ Zip: 98528 _
Contact Number (360 ) 277-3778
Washington State Fireworks License lnf+orrnation (Copy Required)
License No.: Date of
WSPFL-00848 Issue: 01/22/2010
Pyrotechnic Operator License 0 Fireworks Stand License
Bond or Certificate of insurance
(Cary of Certificate f Baal Required)
Provider: SEE ATTACHED INSURANCE
Insured:
Certified Holder.
Location of stand/display
Address: SAFEWAY #1571 23961 NE ST RT 3 BELFAIR, WA
Directions to Site:
Parcel Number: - -
Legal Description:
Legal Property Owner: SAFEWAY
* Please see the reverse side to complete your application
T
TIC uat'ortut don MUST bopr�oykwmtkte site dow
Locations and sak distances from the back, sides and fit of retail sales�or
deli ed ftlaam to:
• Fire Hydrants • Property Lines
• Buildings • Parking
• Combustibles . Public Roads and Ri ft of Ways
Fire Lanes • Private Roads and Right of Ways
Trees/Brush Landmarks
• Utilities and Gas • Mortar separation distance
• Designatedlanding area
"PLEASE SEE ATTACHED DIAGRAM
Appli ife Aftavft
l certify that the information provided herein is accurate and that compliance with
all County, State and Federal Ism pertaining to the sales or discharge of fireworks
shall be maintained. y�
Signed' \:• DU�1 FOR TYSON DEVRIES Dates 05/25/2010
FOR OMCtAL USE ONLY BELOW T MS LINE
Accepted By: Date:
r
MASON COUNTY FIRE _MARSHAL
Mason County Bldg.111426 W Cedar St
PO BOX 186 Shelton,WA 98584
(360)427-9670 Ext.273
CODE ENFORCEMENT FIRE INSPECTIONS FIRE INVESTIGATION PUBLIC EDUCATION
STANDARDS FOR THE OPERATION OF RETAIL FIREWORKS STANDS
Sales
Consumer fire works may be sold only On the following days and times.
• June 28th from 12 noon to 11PM
• June 29th—July 50' from 9AM to 11PM
• July 6th from 9AM to 12 noon
• December 27th—31St from 12 noon to 11PM
Approved Fireworks
Only Washington State Fire Marshal approved Class C common fireworks may be sold.
Fireworks Stand Location
• A fireworks stand shall not be located more than 150' from an approved access road,
• Shall be at least 100' from another fireworks stand or separated by a road, street or highway at least
30' in width,
• Shall not be located any closer than allowed by the table below to other structures or exposures,
• Or be located closer than 100' from any flammable liquid or gas dispensing device, or 300' from any
flammable liquid or gas bulk storage or dispensing facility.
Retail Fireworks Stands—Minimum Clearances
Buildings Combustibles Property Line Parking Motor Vehicle Motor Vehicle
Traffic, Traffic,
Public Road Private Way
Back of Stand 20' 20' 5' 20' 20' 5'
Side of Stand 20' 20' 5' 20' 20' 5'
Front of Stand 20' 20' 20' 20' 20' 20'
There shall be a minimum of 2 (two) approved 2 1/2 gallon pressurized water fire extinguishers
located adjacent to each exit door.
• Cooking, open flame or any type of open flame equipment is prohibited in a fireworks stand.
• Fireworks stands shall be locked when unoccupied and not open for business if fireworks are stored
in the stand during these times. Fireworks stands shall not be locked when occupied. Fireworks
may be removed or transferred to a temporary storage structure or location approved as part of the
license and permit.
• Fireworks may be stored in a locked and secured retail fireworks stand,truck, container,or trailer
that is at least 20' from the fireworks stand during business hours, or in a locked or secured metal or
wooden garage,shed,barn or other accessory building that is a least 20' from the fireworks stand.
• At least one person 18yrs of age or older shall be on duty in the fireworks stand when fireworks are
being sold to the public. Such person shall be responsible for the supervision of the fireworks stand
and its operation. No person under the age of 16 shall be allowed to occupy the fireworks stand
when it is open to the public.
• It is illegal to knowingly sell fireworks to persons under the age of 16. A sign stating"No Sale Of
Fireworks to Persons Under the Age Of 16"in letters at least 2"high and in contrasting color shall
be posted on the front of the stand. A photo ID is required and it is the responsibility of the seller to
require proof of age. Driver's License or Photo ID showing a date of birth issued by a public or
private school, state, federal or foreign government is acceptable.
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
WWH6551
TO: Governing body 4 city,town, or county in which DATE OF JAN.02, 2010
fireworks stand will be located. I APPLICATION:
Applicant Name: Address.City,State:
BELFAIR ASSEMBLY OF GOD 2120 MILWAUKEE WAY,TACOMA„ WA 98421
Sponsor(H other than applicant): Address.City,State:
TYSON DEVRIES 2120 MILWAUKEE WAY, TACOMA„WA 98421
Location of proposed fireworks stand: [Enclose drawing of stand location]
23961 NE STATE RT#3 BELFAIR,WA SAFEWAY#1571
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
=- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIF;EWOR�KS STA D�T PERMIT
- For The Fireworks Sales Year Of. - 2010 - -
(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 j
authorized to sell U.N. 0336 1 AG Consumer fireworks at the location designated herein between the
following date and times:
Sales For July 4 h Sales For December 31"
From: From:
To: To:
Sponsor: BELFAIR ASSEMBLY OF GOD
Location: SAFEWAY#1571 23961 NE STATE RT#3 BELFAIR,WA
/s/ /s/ FOR TYSON DEVRIES
Signature of Official Granting Permit Signature of Applicant
Title: Agency:
Date: Permit Number:
Licensee Name: BELFAIR ASSEMBLY OF GOD License Number: 00848
3"420-013(Rev.2/05)
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CERTIFICATE OF INSURANCE ISSUE DATE
ACORD,� 04/27/2010
PRODUCER This certificate is issued as a matter of information only and confers.no nights
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 4015727097 11/01/2009 EACH OCCURRENCE $ 1,000,000
®commercial Generai usmity 11/01/2010 FIRE DAMAGE $ 200,000
❑calm°Made M Occurrence MEDICAL EXPENSE $ EXCLUDED
❑Owners'and Contractors'Protection
PERS.AND ADVERTISING INJURY $. 1,000,000
❑ GENERAL AGGREGATE $ 2,000,000
General Agogate Urnit mires Per: PRODUCTS AND COMP.OPER.AGG. $ 2,000,000
❑Puicy LJ Project ®Loon
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
❑i°ny Aitaniobi1s BODILY INJURY Per n $
❑AN Owned Automobiles
❑scheduled Automobiles BODILY I raccident) $
❑Hired Automobiles PROPERTY DAMAGE Per e't $
❑Non-owned Automobiles COMPREHENSIVE
❑ COLLISION
WORKERS'COMPENSATION WC Statutory Limit Other
AND EMPLOYERS'LIABILITY EL EACH ACCIDENT $
EL DI SE(Each employee) $
EL DISEASEI' Limit $
EXCESS LIABILITY EACH OCCURRENCE $
❑Occurrence ❑Claims Made AGGREGATE $
$
$
Re:Safeway located at 23961-NE St Rt 3 in Belfair,WA(W WH6551)
The Certificate Holders are named as Additional Insureds 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 CERTIFICAT(:HOLDER NAMED TO THE
LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
Safeway ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Beifair Assembly of God
Mason County Authorized Representative
PO Box 186
426 W Cedar y�
Shelton,WA 98584
Page 1 of 1 Certificate ID 9 CMEY2B2G
SITE DIAGRAM
Date Updated: J y 2�10 Location #: w W (055 1
Location Name: Ordinance Of: MASO v) G O Vt h
Site Address: 1?J q V] N G a. R-�, 3 Structure Size: 2�4, �Ot,nd
CITY STATE/ZIP WA- °I$52$ Structure Faces: Parcel:
S ova a# setback from str CtUres, gas fire lanes, public and -or,vats rc�ac s pro er i`nes tens and lar�cr�arl<s
s�
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Notes
May 25, 2010 \
Fire Marshal a
Mason County
PO BOX 186
426 W Cedar ,r,
Shelton, WA 98584
Dear Fire Marshal,
In preparation for the upcoming 2010 4th of July season, please find enclosed
with this letter all information apply for a fireworks stand permit.
I have also enclosed 1 check, totaling $100.00, check # 30001117 , for the
Permit Fee.
If you have any questions or require further information please feel free to
contact me at (253) 922-0800.
Thank you for your time and attention to this matter.
Sincerely,
Brenda Merrilf
Licensing & Permits
American Promotional Events, Inc. - Northwest
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.tntfireworks.com
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L, Point Land t Isolated Footings INSULATION Date By m
BO;/8URB INSULATION3
Date By Date By FIRE DEPARTMENT W
Foundation WWI* Floors Dale By �
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Date By Data By PROPANE TANKS 0
PLUMWNI^a vault Date By p
Date By OTHER 0
Groundwork AM C
Dada By `type:
Dale By Date By
DXV DRYWALL Type:
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By Data By Drla By
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Type of lnsp. Fall Date Dante Done By Comments
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