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HomeMy WebLinkAboutFIR2018-00028 Final Fireworks Stand - FIR Inspections - 6/1/2018 -nf �s E N - CONCRETE MECHANICAL MANUFACTURED HOME L Footings t Setbacks (]gate �� Ribbons 17 � Gas Piping � C intefiorDate By Interior-hate By Date By � L 00 Exterw slate By Exterior-Gate By Set-up 0 no Point toad r Isolated Footings INSULATION ���� �y Z o BG l BLAB INSULATION Date By Date By FIRE DEPARTMENT Foundation Walls Floors Gate; By Date By Data By DECKS FRAMING Walls _ cute By Date By Gate By PROPANE TANKS PLUMBING vault gate By Date By u� OTHER Groundwork Antic Date By Date By Type: data By DRYWALL O.Wv Type Int.Brace Wail pate B Clete By y y pate ` FILIAL IN PECTION _ N m Waterline Fire Seperation 0 aData By slate By Gate � f vJ By F Aft � o o Pass Or Request Inspect. o Type of Insp. Fail Date gate Dane By Comments 00 3 i"1 1 a m (D y A O 7 N 0 W 1 N (Q (D O v AGE C7►R CERTIFICATE OF LIABILITY INSURANCE °"o3120/20;8'""' 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(ies)must have ADDmONALINSURED provisions or be endorsed.If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement,A statement on this certificate does riot confer rights to the certificate holder In lieu of such eruforsement(s). ' PRODUCER CONTACT NAME: DAVID CONNOLLY INSURANCE AGENCY INC. PHONE FAX 9393 BAYSHORE DRIVE (A/c,NO,EXT).360-692-6439 (A/C,NO): I E-MAIL SILVERDALE WA 98383 !ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 8 INSURED INSURERA: NATIONAL FIRE&MARINE COMPANY INSURER B: HALO FIREWORKS LLC 15156 NW HITE CENTER RD : INSURERC: INSURER D: SEABECK WA 98380 INSURERE. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALLTHE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDTL SUER pOLtCYNUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE s 1,000,000. CLAIMS-MADE 'OCCUR DAMAGETORENTED PREMISES(Ea Occurrence) '$ 100,000 MED EXP(Anyone person) $ 5,000 A X 72LPS031025 04/01/2018 04/01/2019 PERSONAL&ADV INJURY $ 1.000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: � $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ k (Ea accident) a d ANYAUTO BODILY INJURY(Per person) $ OWNEDAUTOS SCHEDULED V BODILY ONLY AUTOS J (Peraccident)$ i j HIREDAUTOS NON-OWNED PROPERTY DAMAGE $ i I ONLY AUTOSONLY (Per accident) 9 UMBRELLALIAE OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ Li DED RETENTION$ $ j} WORKERS COMPENSATION PER OTHER $ AND EMPLOYERS'LIABILITY STATUTE ANY PROPRIETOR/PARTNER/ y/ry ' E.L EACH ACCIDENT 8 EXECUTIVE OFFICER/MEMBER N/A EXCWDE D7(Mandatory In NH) E,L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF c OPERATIONS below E.L.DISEASE POLICYLIMIT '3 i } i I a DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may beattachedifmorespaceisrequired) Boomtown Productions LLC,Mason County,Property Owner Joe Solis are listed as additional insured for the fire work stand a122950 Slate Route 3 Belfair,WA, dd 98528 x4 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE RIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BOOMTOWN PRODUCTIONS LLC DATE THEREOF,NOTICE Yfin BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 15156 NW RITE CENTER RD AUTHORIZ REP NTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION.All Rights Reserved i 31.1769 11-15 The ACORD name and logo are registered marks of ACORD �y REC IVED ` JUN � 12p� MASON COUNTY (360)427-9670 Shelton ext.352 DEPARTMENT OF COMMUNITY .01dK V0d (360)275-4467 Belfair ext. 352 ` BUILDING• PLANNING • FIRE MARSHAL (360)482-5269 Elma ext. 352 Mason County Bldg. Ili, 426 West Cedar Street 1854 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20J a-C 22) 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: -�OGc1 �irU�UG�O1'1�j L. l-.G Mailing Address: 1615tp n 46 "-ail: i : .Q. AD&, .k. State: _�Zip: 8 �O Phone#: ;j Lao• (Q;ko• I rl ;k C �' Sponsor Information: Name: .J p Address: �9*,DVG City: _ State: Zip: Phone #: Email: Washington State Fireworks License Information (Copy Required): License Number:6.6,j, , no. 6 n• 1 )� Date of Issuance ❑ Pyrotechnic Operator License Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: .-�LE E A+ 1 h ecL Insured: Certified Holder: Location of Stand/Display: _ Site Address: A Q Sd V 1 C & D' e tions to Site: Parcel Number: (tw ve digit number) d 0 _ Legal Property Owner Loce ttcl m **Please see reverse side to complete your application** IACommunity DevelopmentTIRE MARSHALTireworks Permit application.doc 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 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 Date DCommunity DevelopmentTIRE MARSHAUFireworks Permit application.doc 1 , . 1 t: FIREWORKS STAND} SITE PLAN SITE DIAGRAM DATE UPDATED: 5/23/2018 LOCATION NAME: Belfair Stand PARCEL NUMBER: 123325000044 ORDINANCE OF: Boomtown Productions SITE ADDRESS: 22950 NE State Route 3 STRUCTURE TYPE: Wood CITY&STATE: Belfair,WA STUCTURE SIZE: 32 x 8 CROSS STREETS: State Route 3 & NE Roessal Rd STRUCTURE FACES: West - , ' a t Y aa F * t „m �i .