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HomeMy WebLinkAboutFIR2016-00016 Final Fireworks Stand - FIR Permit / Conditions - 6/23/2016 /) - E \ ! 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E . = ! \ § k ! .1 y # ! \)) (\ k LL L | , w TL t ` > W a0z Q � oes ƒ 26 - - f -0 . \ « © a CD \\ < CD 22� o Q ! 0 e r ■ \ ( k« d\ iB cu - ome LL o . « � ( ! � -n 3 CONCRETE MECHANICAL MANUFACTURED HOME 1= CD Footings I Setbacks Dale By emit Piping asPlne Ribbons � OInterior Do to By Interior.Date By Date By O Exterior Date By Exterior-Date BY Sot-up O INSULATION Z t7t Point Load I Isolated Footings 8G I SLAB INSULATION Dale Date By Data By FIRE DEPARTMENT Foundation Wails Floors Date Date By Data BY DECKS FRAMING Wails Date Er Date By Data By PROPANETANKS PLUMBING Vault Date BY Date By OTHER Groundwork Attic Type. Date By Dale By Dale By D.W.v DRYWALL Type Int.Brace Wall Date By � Date By Date By X p1 FIN WPEON ro N m Water Line Fire Separation O Dale By Date By Da 01 O 0 Pass or Request Inspect. c pe of Insp. Fail Date jLjbatea Done By Comments Q, 0 0 f a d ro N O O O J C O J N O N N 3 m m 0) 0 m MASON COUNTY (360)427-9670 Shelton ext.352 a t DEPARTMENT OF COMMUNITY DEVELOPMENT (360)276- 467 Beffair ext.352 BUILDING. PLANNING a FIRE MARSHAL (360)462-5269 Elma ext.352 x Mason County Bldg. III, 426 West Cedar Street PO Box 279. Shelton, WA 98584 www.co.mason.wa.us RECEIVED ,or (� MAY 2 3 2016 Mason County Fireworks Permit A `OS 615 W. Alder Street fAA t 6 Incomplete applications will tppt� SPA" A permit for retail sales or public display of firew application with required documentation and fees s tZ review. A permit will be issued upon satisfactory sit tC Applicant Information: ool pE Owner: J A, /4;llev tWZ ttV. Mailing Address: IGI" ^'w got- Ca.4.- City: Te4C,.L=- - a e:w/>- Zip: ?sj$0 Phone#: 360- 6 20-173z- Email: J A &Wi Sponsor Information: Name: Paow-t-awn P. 4,, ear LL-L Address: /Sr6-6 uj H,`t�& Ce.4cr R4 City: Se.t,„t_ State: Ug Zip: q&,gn Phone#: Email: mile "ISa /...4»..;I, r a, Washington State Fireworks License Information (Copy Required): License Number: 1�v - 0 '7 4 9 Date of Issuance MAI 2-, ZO/(e ❑ Pyrotechnic Operator License Fffireworks Stand License Bond or Certificate of Insurrance (Copy of Certificate/Bond Required): Provider: _bavl I ecK^.111 r� JMt rya` tR Insured: paor.�lO +. dw�+lons, /14Se� C•au.1 Sec Soft Certified Holder: g .e. -1-o w. Pr. d.,+,o .s LLC- Location of Stand/Display: Site Address: 2 2 9 5o Ng S(.44- Q.6L.4e31 4el-x.i, Directions toSite: Cer .i aF ue sia Qo,4e3l9CI�a1�- pE ko ,essa.i Qd u� Ki -l0 3el a� Ele ..+s nn Parcel Number: (twelve digit number),2332ti ZS - s aao 4y Legal Property Owner 6.FM Prop er*cf 1,-& "Please see reverse side to complete your application" 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 Sc "r f,+{ PL0.n Applicants Affidavit I certify that the information provided herein is accurate and that compliance with all County, State an ederal laws pertaining to the sales or discharge of fireworks shall be tained. ed Date 5-22—I,6 RECEIVED MAY 2 3 2016 ysbON �LNrt 615 W. Alder Street FIREWORKS STAND SITE PLAN SITE DIAGRAM DATE UPDATED: LOCATION NAM1 9tGF/9/.2 ,S/�9 /V16 PARCEL NUMBER:/Z33Z5-000Qtz ORDINANCEOF:1?V"7bb,/,V /'2oDVc ?J0411 SITE ADDRESS: 22-11s p " Si.jejj;e 3 STRUCTURE TYPE: WOO D CITY&STATE:,e5c7r�/2 Wf4 STUCTURE SIZE: 3 Z X Y CROSS STREETS:1?7 709r 3 & LZ,ccA exg STRUCTURE FACES: P&SS' 4 • Q .: vm e rT 8 fjtT A��® CERTIFICATE OF LIABILITY INSURANCE (a"""YYY'') THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONF 03/30/2016 ERS NO RIGNT9 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. IMPORTANT: It the ceAificate holder is an ADDfTIONAL INSURED,the p: 1,1las)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms antl conditions Of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holtlar In lieu of such endorsement sl. PRODUCER David Connolly Insurance Agency Inc. ^NONE 360�92-ti439 --- 9393 Bayshom Dr. Silverdale — IInAFPORDNG covgrADE caeca WA 98383 ar FtOtA: NelbnW Fag 8 Marine Ins.Company INSURED --- --- Halo Fireworks LLC INBN 11111 - 15156 NW Hite Center RD INSURER C: INSURER D: — - Seabeds WA 98380 INaUpgf!_ - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSU1: TTO THE INSURED NAMED ABOVE FOR TH POU INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE T HIC IS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT O THE EXCLUSIONS AND CONDITIONS OF SUCH POUCI ES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. S'Man LTR TYPE OF slaossNCE MWD YE" real EXP CY NUY6ER Is oD x I COMMERCIAL GEIIERAL LNgWTY EACH OCCURRENCE 6 1,000,000 CIA j J IMaMAOE IHT �OCCUR PREWS fE. _ i 100,000 A am ErF(An .. enm 6 5.DOO L AAOREDATE X 72LPS-02S3 04/012018, 04/0112017 PERSONAL iADV INJURY 11,000,000 NGEN pInIMprt APPLIE S PER!, 50 POLICY L JECT J LDC GENERAL AGOREILkTE 5 2,000.000 OTHER. PRooU Ts-COMWOPAGO a 2,000, AVIDItDpIF LIAYl1ry i ANYAVTO �AU -O 0SuEDULED BDOLYINJURY(Per Perron) f F-, NON-OWNED B004Y INAlRV IPar actlerMl_ 5 HIRED AUTOS L_I AUTOS P P GE DAMA 6 KANada UTARELLA Lly a OCCUR Excessi-His CLAM e AWUE i EACH OCWRRENCE a. D I II RETEMIONa I I.AGGREGATE J a ,WORLEAB COMPp1aAnON I AND EMPLOYERS'UAep.RY YIN A ANY PROPRIETDRNARTNEWE%ECURVE OiPI`=EMS"EXCLUDE Di NIA I I 11IACN ACC4IENT a (YendAtory In NMI N yyeeaa deu,ae under E.L.019EA6E-PA EMPLOYEE S DESCRI ION OF OPERATIONS velar EJ..OIaFASE-POIA:Y LIMB I a I DESCRVnON OF OPERATIONS ILOCATIDNa!VENCLEg IACORD t01,Add I10"Atserb SotseuN,seT W Mfaotsi Nsm a f N r dj Boomtown Productions LLC.Mason County,Property CWner Joe Sella are listed as additional Insured for the fire work stand at 22950 State Route 3 Bel fair. WA 98528 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BOOmIOWO Productions LLC ACCORDANCE WITH THE POLICY PROVISIONS. 15156 N W Hilo Center RD A C REPREserrrAnvE Seabeck WA 98380 •2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD