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HomeMy WebLinkAboutFIR2016-00021 Fireworks Final - FIR Inspections - 6/23/2016 \\ / o CL \ ( & @ E -04 2M \ \\ LL j } \ � 00 ! G ( § UJ ¥ § o 0T � / _ _ ) k \ / 0 a _ ) 0. ) z \ \ E a ® e � - S - > z co v / w § \ § ■ § \ Bd ( k o e G 5c 0 k ) ƒ k } � O ■ _ z ° � � \ � - Q ƒ * ƒ 2 b = ( j o ( CL IL \ j / \ n (L o � \ z � w \ > $ & \ + 6 e = o k LO\ � � � � \ \ / 0 / z0 - E � n � - m " zzzzf \ . 0 / < 6 z aee _ at § E6t222 ) 2 § \ ) ® § 46 ± $ w � ) 3 ] ) S 0 s £ Q = \ S \ § ® § \ ® \ k5c 0 ( f % \ \ § � � ) \ ) < k L)(n o ; § 2 \ ° � 0 § f E � Z "n MECHANICAL MANUFACT=HOMEE000NCRETEDate By Footings !Sethxks ties Pi In RlhhonsP gInterior Date By Interior-DateBY Dala3 O n 00 Exterior Date By Exterior-Date B Set-upyPoint load I Isolated Footings INSULATION DalaZ BG l SLAB INSULATION FIRE DEPARTMENT m Date BY Date BY Foundation Wails Floars Date By m Dale By Date By DECKS m FRAMING ten" Dam By m Date BY Data By PROPANE TANKS Vaud Dale By PLUMBING Date By OTHER Groundwork Attic Type. Date By Date By Date By DRYWALL Type. -n D.W.V Inc Brace wan Date By d Date By Date By FINAL IN PECTION ^' O 0 Water L1ne Fin Separation ,,/ 0 Dale 8y Date BY /1 r a Date By O g Pass or Request Inspect. 5 T of Insp. ail Date Date Done By Comments t ` o N 0 f m w w 0 n O a 0 O w 0 N r d m M o_ J MASON COUNTY (360)427-9670 Shelton ext.352 DEPARTMENT OF COMMUNITY DEVELOPMENT (360)2764467 Belfair ext.352 BUILDING. PLANNING. FIRE MARSHAL (360)482-6269 Eima ext.352 Mason County Bldg. III, 426 West Cedar Street A.,. PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 /V _ 000� Mason County Fireworks Permit Application Incomplete applications will not be accented 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: NORTH MASON PEE WEE Mailing Address: 3o2 NE HAVEN LAKE DR_ City: TAHUYA State: WA Zip: 98588 Phone#: 263.208.3235 Email: 5-.%*r.-FPh1gDtntljreworkscom Sponsor Information: Name: RAYMOND MOW Address: am NF HAv N i AKF nR City: TAHUYA State: WA Zip: 98588 Phone#: 253.208.3235 Email: Iisicich10tntfireworks.com Washington State Fireworks License Information (Copy Required): License Number: WSPFL 16-0248 Date of Issuance 02/08/2016 ❑ Pyrotechnic Operator License m Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: SEE ATTACHED Insured: Certified Holder: Location of Stand/Display: Site Address: OFC - NE 1403 OLD BELFAIR HWY-BELFAIR WA Directions to Site: Parcel Number: (twelve digit number)—Z24---q1-- Legal Property Owner "Please see reverse side to complete your application" —n x�Ills' s Tj 0 z ct el� U � 5 Y� 1 �Jl ,e I r gn QIp iJ �_? 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 SEE ATTACHED DIAGRAM Applicants Affidavit I certify that the information provided 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 [J—� Date 02/09/2016 ACC OR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDINYYYY) lk� 11/1/2016 2/9/2016 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les) 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 endorsements . PRODUCER Lockton Companies CONTACT OONTCT 3280 Peachtree Road NE,Suite#250 PHONE FAX Atlanta GA 30305 E#WL c Ne: (404)460-3600 ADDRWI N AFFORDING COVERAGE NAIC1 INSURER A:Everest Indeninity Insurance Company 10951 INSURED American Promotional Events,Inc. INSURER 0: 1359629 DBA TNT Fireworks,Inc. INSURER c: P.O.Box 1318 NsuREa o: 4511 Helton Drive Nsuz E: Florence AL 35630 INSURER F: COVERA CERTIFICATE NUMBER: 12253602 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MR TYPE OF INSURANCE POLICY NUMBER MM U EFF flHIMO/YYYYJ TR LIMITS A X COMMERCIAL GENERAL LIABILITY Y N S18GL00242-151 11/l/2015 II/l2016 EACH OCCURRENCE s 1 000000. CWMSMAt OCCUR PREMISES ...I S 500000 MED EXP(Any.pI f.5 000 PERSONAL SADV INJURY S'. 1000000 GENL AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE $ 2,000,000 POLICY❑JEPRO- CT 0 LOc PRODUCTS-OOAIP/OPAGG 112,000,000 OTHER: 5 AUTOMOBILE LIABRRY NOT APPLICABLE (COMBINED I LIMITxxxxxxx ANY AUTO BODILY INIURY(Pwpenm) it xxxxxxx OWNED SCHEDULED S �BO SCHEDULED BODILY INJURY(Par Wddent) HIRED AUTOS AUTOS NON-OWNED PROPERTY DAMAGEAGE s )DDO . $ XXXX}IXX UMBRELLA Lug I OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAR CLAMSduOE AGGREGATE $ XXXXXXX DED I I RETENTION It s XXXXXXX ANR�uCYE OMPENIATIONBILIT YIN NOT APPLICABLE sTA H. I ANY PROPRIETORIPARTNERIE)(ECUrNE E.L EACH ACCIDENT s XXXX]� OFFICERIMEMBER EXCLUDED? ❑NIA (Mendetoryin NH) E.L DISEASE-EA EMPLOYEE S XXXX)= If yyeeaa deealbe ender DESCRIP ION OF OPERATIONS below EL DISEASE-POLICY LIMIT I s XX DESCRIPTION OF OPERATIONS I LOCAM ONS I VEHICLES(ACORD 101,A nal ReOerae ScM la.nay W aBaeMd N Tole specs N n e,ullem Tres CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES PDA THIS HOLDER,APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED. located at QFC,NE 1403 Old Belfair HWY,Belfn r,WA(W W M6505)Certificate holder is an additional insured on the General Liability As required by written contract subject to policy terms,conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION 12253602 Mason County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Mason Pee Wees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 186 ACCORDANCE WITH THE POLICY PROVISIONS. 426 W Cedar Shelton WA 98584 AUTHORIZED REPRESENr 00 7 F i @ 1989--2014 ACORD CORPOFIATION. All rights reserved. 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