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Home My WebLink AboutFIR2016-00027 - FIR Application - 8/17/2016 boy MASON COUNTY (360)427-9670 Shelton ext352 DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext 352 BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext. 352 y Mason County Bldg. 111, 426 West Cedar Street H5' PO Box 279. Shelton, WA 98584 www.co.mason.wa.us 32233 -Sb-000ly - x�e/ GACnF,'e_L( a j'!'8drV%(L, o,�pi 'R20 Ib - oacZ Mason County Fireworks Permit Application Incomplete applications will not be accepted 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: Wolverine West Fireworks Mailing Address: PO Box 628 City: Centralia State: WA Zip: 98532 Phone#: 360.790.3409 Email: aaron@wolverinewest.eom Sponsor Information: Name: Alderbrook Resort & Spa Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone #: 360.898.2262 Email: eindy.sund@alderbrookresort.eom Washington State Fireworks License Information (Copy Required): General Display License License Number: C-04138 Date of Issuance 1130/16 ❑ Pyrotechnic Operator License ❑Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: Professional Program Insurance Brokerage Insured: Wolverine Fireworks Display, Inc. Certified Holder. Adam & Anne Farrens Location of Stand/Dis av Site Address: It1 E _ �P'pck_ pP_.0 tC &1'y Directions to Site: see attached Parcel Number: (twelve digit number) Fired on Puget Sound Legal Property Owner n/a "Please see reverse side to complete your application" RECEIVED AUG 0 3 2016 615 W. Mdoi Sweet 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 TreesBrush Private Roads and Right of Ways Utilities Landmarks see attached 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 mainta�d Dlgi Wily signed by Aarm FL Webb 'H DN:m Aamn B.Webb, ron Re Signed o Wolverine West.LLC, late 6/2l16 ov= spay anger, Webb _Emill-�i( <=U5 Date:2016,08.02 11:571.08-OrW �i�i� oArf or narucAnon *�� APPLICATION PART I *t �' FOR PUBLIC FIREWORKS DISPLAY PERMIT 812N6 TO: Governing body of city, town, or county in which display is to be conducted. NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 360.790.3409 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E Hwy 106 Union, WA 98592 360.898.5529 PYROTECHNIC:OPERATOR NAME ADDRESS IJCENSE# Aaron Webb 5030 180th Trail SW, Rochester WA 98579 P-04311 NAME-OF ASSISTANTS: at least one re uired NAME ADDRESS AGE Chad Beebe 11210 Saskatoon Ln Olympia WA, 98506 P-04312 NAME ADDRESS AGE _EXAC'f.LOCA7 DJ,OFPROPOSED:DISP r+ - • �- - - ,::+: LOCATION Alderbrook Resort & Spa -7101 E Hwy 106, Union,WA 98592 DATE 9/3N6 TIME9pm i4WMBER AND KINDS'OF FIREWORKS TO BE DISPLAYED -" Not to exceed:(10) multi shot cakes, 30 - 3" shells, 20 - W' shells �—Rvwk—r=R&PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Local Fire Authority) In our approved magazines vein v-,— SIGNATURE OF APPLICANT .FINANC"RESPONSIBILITY 3 y ::' BONDING OR INSURANCE COMPANY (Mark One) Professional Program Insurance Brokerage ® Bond or ceri ficate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 371 Bel Marin Keys Blvd. Ste. 220 Bond or certificate of insurance shall provide minimum coverage of Novato, CA 94949 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II PERMIT / PERMIT# DATE: In accordance with the provisions of RCW 70.77 and applicable local ordinances is p�onduct a fireworks display as per the above application. ; k FIRE NAME: (Full name of person,firm, RESTR TIO//NN,S: E (DL � DODES ppESaEECStOPiS Oy pµt58 �CONSRAC�ttON SH LPP OVW Permit of valid without verification of cta1U the appropriate State Fireworks License � OUtREC Rp_(OaS Y vE � EtpWS OOEs uiv c� LICENSE NUMBER: V ` (Instructions on reverse side) 3000A20-050(R 02105) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee .ac Rd CERTIFICATE OF LIABILITY INSURANCE DATE(MMMNYYY) 5/1 312 0 1 6 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 policy(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 endomemen s. PRODUCER CONTACT NAME The Partners Group Ltd -PHONE F 11225 SE 6th St., Suite 110 MAC/c`INL°i Bellevue WA 98004 oDm3s;rjasaenQW[p corn INSURERS AFFORDING COVERAGE NAIC9 INSURER A: INSURED 15539 INSURER B: Wolverine West, LLC INSURERC: Wolverine West Fireworks INSURER D: PO Box 628 Chehalis WA 98532 INSURERE: W SURER F: COVERAGES CERTIFICATE NUMBER:456473472 REVISION NUMBER: 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 A MS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�T�R TYPE OF INSURANCE POUCYNUMBER MADML sum PWJCY EFT MIDYFJIP GENERAL LIABILITY Y CPP010545600 5/1/2016 51112017 EACH CURR CE s1,o00,00o X COMMERCIALGENERALUABILITY RFMI E T1, 5100,000 CLAIMS.MADE FTIOCCUR MEDEkP wiytini,.pavan] shvA PERSONALS INJURY $1, 0 GENERAL AGGRE S WA GEN'L AGGREGATE LIMB APPLIES PER; PRODUCTS-COMPAOP AGG S2000.000 Poucr 2FA Loc F AUTOMOBILE UABWTY Ea acrJeanl ANY AUTO BODILY INJURY(Parparpn) s ALL ED SCHEDULED BODILY INJURY(Par*D*W U s HIREDAUTOS NONE ED. PROPERTY DAMAGE S S A UMBRELLA LIB OCCUR ELP001218200 SM12018 S1112017 EACH OCCURRENCE $4.000.000 X EXCESS LIB CLAIMS-MADE AGGREGATE S4,000,000 DED I I RETENTION s WORKERS COMPENSATION WC STAT- 0 H. AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT $ OMCERRAEMBER E)(C1-UDED9 NIA (rMIMSIwy In NH) E.L DISEASE-EA EMPLOYE S tt Yea.damzlDa,ntlar DESCRIPTION OFOPERATONS Miw EL DISEASE-POLICY UMr 3 DESCRIPTION W OPERATIONS I LOCATIONSI VENrUS IMaah ACORO 101.AetlNwMi Ramarb 9pM4uls,I nwre Naca b raqulm4) Samd Patel Family,Alderbrook Resort&Spa, Mason County&Its employees ATIMA are Additional Insured as respects the 9/3/16 Aerial Fireworks Display located at Alderbmok Resort&Spa,7101 E State Highway 106, Union,WA 98592. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Samit Patel Family THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 NE Summerwood Dr ACCORDANCE WITH THE POLICY PROVISIONS. Elgin OK 73538 AUTHORIZED REPRESENTATIVE O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED — FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional insured: 1. The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on behalf of the Named Insured, but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. All other terms and conditions of the policy remain unchanged. CG133F(07/95) m M 2 /vr t Y[ w N J : �{ "llt- r , •. o 3 0 V r, e r M ' I`.� f•1 40% 0 N QI �' P i ;w Jeep _ �=1..J4, h4C?} 1 -