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HomeMy WebLinkAboutFIR2020-00012 Fireworks Stand - FIR Permit / Conditions - 5/6/2020 i W E W W W W 00 Z d d O U) a W � a O a z U) z co Z Z LO co 00 U') rn U) 00 0 U) Y i ° Q V 0LO = w of w O M cd m LL z ZCL - O `" 0 0 z = OVC � ( o rn0) E a 0 V N LU co N U M (�j CL W U) O c W A M 0 LO ♦ii^ a) 55 v' W W f� U Z Q O O W y ° c a a G w E LO Q Q J E U W Q ° U J J a � y z Z z— N_ w O O � O W O O O — Z w M Q W z cV V U O c V .O a a Z c H W W `o Z V H H a a 0 U V ii Mason County B Mason County - Division of Community Development 615 W.Alder St. Bldg.8 Shelton, WA 98584 360-427-9670 ext 352 www.co.mason.wa.us FIR2020-00012 FIREWORKS STAND APPLICATION & STANDARDS PROJECT DESCRIPTION: FIREWORKS STAND: NORTH MASON PEE ISSUED: 06/16/2020 WEES SITE ADDRESS: BELFAIR EXPIRES: 12/13/2020 PARCEL: 123294190022 APPLICANT: ACAH INVESTMENTS LLC OWNER: ACAH INVESTMENTS LLC 5312 PACIFIC HWY E 5312 PACIFIC HWY E TACOMA,WA 98424 TACOMA,WA 98424 FEES: Paid Due Retail Fireworks Stand Permit $100.00 $0.00 Fee Totals : $100.00 $0.00 REQUIRED INSPECTIONS Fireworks Inspection CONDITIONS ELECTRICAL SUPPLY& USAGE: WAC 212-17-21513 Retailers of fireworks-Stand use and construction. (1) Fireworks may be sold from: (a)A permanent structure which meets provisions of WAC 212-17-21505(3). (b)Temporary, stable structures made from wood, metal,fiberglass or other material.Any temporary fireworks retail stand greater than four hundred square feet shall meet the requirements of a permanent structure, except tents or canopies as defined in the International Fire Code retail stand greater than four hundred square feet shall meet the requirements of a permanent structure, (c)Tents, canopies, or structures utilizing temporary membrane material.All tents, canopies or Temporary membrane materials structures shall be made from fire retardant material or treated with a fire retardant as identified in the International Fire Code.Any tent, canopy or temporary membrane material structure falling within the scope of the International Fire Code shall comply with those requirements. When those requirements are in conflict with other provisions of these rules,the more restrictive provisions shall apply. Printed by:Adana Paysse on:06/16/2020 09:53 AM Page 1 of 5 i Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg. 8 Shelton,WA 98584 360-427-9670 ext 352 www.co.mason.wa.us FIREWORKS STAND APPLICATION & STANDARDS FIR2020-00012 * (6) Retail sales of fireworks and other products which are holiday related shall be from buildings used for no other purpose. * (7)The local authority having jurisdiction may reduce the minimum separation requirements of this section provided that safety of life and property is not diminished. * (4)No smoking shall be allowed within the retail fireworks stand or within the minimum flagged off area. Signs reading "NO SMOKING WITHIN 20 FEET' in letters at least two inches high, with principal stroke of not less than one-half inch, on a contrasting background, shall be conspicuously posted on all four sides of the stand. " APPROVED FIREWORKS: Only Division 1.4G consumer fireworks, obtained from state-licensed wholesalers, not otherwise prohibited by chapter 70.77 RCW or local ordinance, and holiday related products incidental but related to these products, may be sold in retail fireworks stands. " (3)All heating units shall be listed by a recognized testing laboratory and shall be used in accordance with the listing. Heating sources shall have "tip-over"and temperature overheat protection.All heating devices shall have sealed type elements (i.e., oil filled or water filled radiator type). Open flame heating devices are prohibited. * (4)Retail fireworks stands shall be located as required by Table 212-17-21509 in this section.The minimum required area surrounding the stand shall be marked or flagged, except that flagging and marking shall not block a sidewalk or pedestrian pathway. Flagging need not exceed twenty feet in any direction. NOTE: Clearance distances are not cumulative *Measured from the outer edge of the nearest traffic lane. **If stand is equipped with 135 fusible links which will automatically close all sales doors in case of fire, or is equipped with a wire-mesh screen with openings of not more than one inch which covers not less than 90%of all sales openings " (2) Battery powered equipment, electrical equipment and electrical cords which are used in conjunction with a retail fireworks stand or a temporary storage structure or location must be listed by a recognized laboratory and used in accordance with that listing. If electrical power is supplied by an extension cord, the size of the cord,the length of the cord and the amperage and the voltage supplied shall be in compliance with the requirements of the National Electrical Code, current edition.The cord shall be protected as necessary from"drive-over" and other physical damage. No additional permits from a city or county or state official having jurisdiction shall be required for these temporary uses except as specified in subsection (5)of this section. * (3)Fireworks shall not be discharged within one hundred feet of a retail fireworks stand. Signs reading "NO FIREWORKS DISCHARGE WITHIN 100 FEET' in letters at least two inches high,with a principal stroke of not less than one-half inch, on contrasting background, shall be conspicuously posted on all four sides of the stand. * (2) Delivery of fireworks to a location, or storage of fireworks in a facility, not authorized by the license and permit is prohibited. If the approved storage location is outside the jurisdiction issuing the permit,the authority issuing the permit shall notify the appropriate authorities of the jurisdiction in which the storage is to be located. Printed by:Ariane Paysse on:06/16/2020 09:53 AM Page 2 of 5 N a ON 2 li Mason County BEimm Mason County - Division of Community Development 615 W.Alder St. Bldg. 8 Shelton,WA 98584 360-427-9670 ext 352 www.co.mason.wa.us FIREWORKS STAND APPLICATION & STANDARDSFIR2020-00012 " (6) Fireworks may be stored: (a) In a locked or secured retail fireworks stand; or (b) In a locked or secured truck, container,trailer,other vehicle or anything similar which is not less than twenty feet from the retail fireworks stand during hours of retail sales; or (c) In a locked or secured truck, container,trailer, other vehicle or anything similar which is not less than twenty feet from an inhabited building where the term"inhabited building" is defined as in the International Fire Code; or (d) In a magazine which meets the minimum standards of Type 4 as prescribed by the International Fire Code, and which is not less than ten feet from an inhabited building where the term "inhabited building" is defined as in the International Fire Code; or (e) In a locked or secured metal or wooden garage, shed, barn or other accessory building, or anything similar which is not less than: 20 feet from an inhabited building for storage of fireworks for one or two retail stands; or 30 feet from an inhabited building for storage of fireworks for three or more stands. The term"inhabited building" is defined as in the International Fire Code. * (4)No open flames nor any type of open flame equipment shall be allowed in any temporary fireworks storage structure. * (2) No motor vehicle or trailer may be parked within twenty feet of a retail fireworks stand except when delivering, loading or unloading fireworks. * (2)Temporary retail fireworks stands shall not be located more than one hundred fifty feet from a private way,fire department access road, public road, street or highway as measured by an approved route around the exterior of the stand. The minimum requirements for a private way shall be determined by the local authority having jurisdiction, but shall not exceed the requirements of locally adopted street, road and access standards. * Fireworks may be sold from 12:00 noon to 11:00 p.m.on each day from the 27th of December through the 31 st of December of each year. * Failure to comply at any time with the provisions of this rule or any other applicable regulation shall constitute a violation of chapter 70.77 RCW and may result in the temporary suspension or immediate revocation of the license or permit, closure of the fireworks sales or storage structure,the seizure and/or forfeiture of some or all of the fireworks, and other criminal penalties as specified by law. * (3)A temporary fireworks storage facility or a temporary fireworks storage location shall be authorized as a part of a license and permit if it meets the requirements specified herein. * WAC 212-17-21505 Retailers of fireworks—General provisions. Fireworks may be sold from 12:00 noon to 11:00 p.m. on June 28 through 9:00 p.m. on July 5. Fireworks may not be sold between the hours of 11:00 p.m. and 9:00 a.m.from June 28 through July 3. Fireworks may not be sold from 12:00 midnight on July 4 through 9:00 a.m. on July 5. * STORAGE ASSOCIATED WITH RETAIL FIREWORKS: WAC 212-17-21517 Retailers of fireworks—Temporary fireworks storage associated with the retail fireworks stand operation. (1)Temporary fireworks storage is not permanent fireworks storage. Temporary fireworks storage is defined as storage associated with retail fireworks sales and may only be from June 13 through July 31 and from December 12 through January 10 of the following year. Permanent fireworks storage is associated with retail or wholesale fireworks activities when the period of time of storage is other than, or longer than that specified for temporary storage.Temporary fireworks storage shall be in accordance with this section. Permanent fireworks storage is subject to the International Fire Code and the and local ordinances. Printed by:Ariane Paysse on:06/16/2020 09:53 AM Page 3 of 5 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg. 8 Shelton,WA 98584 360-427-9670 ext 352 www.co.mason.wa.us FIREWORKS STAND APPLICATION & STANDARDS FIR2020-00012 * (5)Retail fireworks stands shall not be located closer than one hundred feet from any motor vehicle dispensing station, retail propane dispensing station,flammable liquid storage, or combustible liquid storage. Retail fireworks stands shall not be located closer than three hundred feet from any bulk storage of flammable or combustible liquid or gas, including bulk plant dispensing areas. EXCEPTION: 1. Fuel for generators as allowed by WAC 212-17-21513(4). 2. Fuel within the tanks of motor vehicles. * (5)Storage of fireworks authorized by a retail license and permit is legal only during the periods specified in this section. * (4)Generators which use combustible fuel and which are at least twenty feet from the retail fireworks stand or the temporary fireworks storage structure shall be allowed. Generator fuel shall be limited to not more than five gallons and stored at least twenty feet from all stands. * WAC 212-17-21509 Retailers of fireworks-Location. (1)Activities or uses subject to this rule shall not be limited in location except where such activities or uses are prohibited or controlled by local development regulation,traffic safety or road construction standards. * SURROUNDING AREA AROUND FIREWORKS STANDS: WAC 212-17-21511 Retailers of fireworks-Area around the retail firework stand. (1)The minimum areas around the retail fireworks stand specified in WAC 212-17-21509 shall be kept free of accumulation of dry grass, dry brush and combustible debris. No parking shall be permitted within this minimum area. * (3)Any two retail fireworks stands shall be at least one hundred feet apart or shall be separated by a road, street or highway not less than thirty feet in width. * Licensees shall familiarize all persons working in a retail fireworks stand with the provisions of these rules. * (5)Compliance with the National Electrical Code, current edition, shall be required for all new, permanent electrical installations including temporary P t ora power drops, subject to possible permit fees. _emp _ * Retailers of fireworks—Cleanup. (1)At the end of the legal selling period, all fireworks must remain in the retail fireworks stand,temporary storage location authorized by the retail permit or another location approved by the local authority having jurisdiction or his or her designee until returned to the suppliers from which they were obtained, or until transferred to an approved location. * (4) Failure of the licensee to comply with subsection (3)of this section shall constitute forfeiture of the clean-up bond and the licensee shall be liable for any clean-up costs incurred by the city or county which exceed the amount of the bond. * (8) No cooking is permitted in a retail fireworks stand or in a temporary fireworks storage structure. * (3) In order to obtain return of a clean-up bond, cleanup of debris associated with the retail fireworks activity and the removal of all temporary structures authorized by the license and permit shall be completed no later than 11:59 p.m., July 15 for the Fourth of July selling period or no later than 11:59 p.m., January 10 for the New Year's selling season. * (2)Cities and counties may require a clean-up bond, not to exceed five hundred dollars, as a condition of the permit,to ensure the removal of all structures and debris from the site. * (9)Temporary fireworks storage structures may be inspected prior to use and other inspections may occur on other days as warranted.There shall be no additional charge for all such inspections. Printed by:Ariane Paysse on:06/16/2020 09:53 AM Page 4 of 5 Mason County Mason County - Division of Community Development 615 W.Alder St. Bldg. 8 Shelton,WA 98584 360-427-9670 ext 352 www.co.mason.wa.us FIREWORKS STAND APPLICATION & STANDARDS FIR2020-00012 I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of Laws and Ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state/local law regulating construction or the performance of construction. Issued By: Contractor or Authorized Agent: Date: Printed by:Ariane Paysse on:06/16/2020 09:53 AM Page 5 of 5 THIS FORM IS INTENDED FOR USE BY LOCAL AUTHORITIES HAVING JURISDICTION(AHJ)IN THE EVENT THEY DO NOT HAVE A PERMIT FORM SPECIFIC IN ADD17ION TO ORINLLIEU OF ANY LOCAL PERMITTING FORM AN OR PROCESS ER FIREWORKS RETAIL SALES(CFRS) MAY EXIST WITH THE LOCAL AHJ.BE REQUIRED Directions: Provided the local jurisdiction has no permit form of their own,complete this permit application and submit it with the local AIIJ portion oryour Retail Fireworks Stand License to the jurisdiction in which you wish to run your CFRS facility. WAS H I N GTO N STATE Mason Co. WASS003 FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New/First Time Applicant ❑X Previous Per North Mason Pee Wee Name of Group,Organization,or Person(Last,First,Middle Initial,and Date of Birth)Issued the Fireworks Reta' ce se Coby Treadway b ei - Name of Permit Applicant(Last,First,Middle Initial,and Date of Birth) OF 2120 Milwaukee Way - Tacoma Washington 98421 vV A/dMb-_ Permit Applicant Mailing Address(Complete Including Street,City,State,and ZIP Code) ( 360 )551-2411 coby.d.treadway@outlook.com ( ) Phone Number E-Mail Address Local Business Number(if required) CFRS Facility Information ❑ Stand ❑ Tent Other: Size: 8 X 32 = 256 sq. ft. Specify Square FeetlDimensions Safeway #1571-(Belfair Valley Plaza) 23969 NE State Route 3 - Belfair - Washington 98528 CFRS Facility Address(Complete Including Street,City,State,and ZIP Code) 10-06180 Safeway Inc./Acah Investments ( ) Name of Property owner Phone Number Parcel Number for Stand Location Fireworks Supplier Information List all of the licensed fireworks wholesalers who will be supplying this stand product TNT FIREWORKS -G20987 Storage Information X❑ on Site ❑ off site: At the stand with security Storage Address(Complete Including Street,City,State,and ZIP Code) ©Sales Structure ❑ Detached Building ❑Truck/Trailer ❑ Other: • Specify CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines. ❑X Application/Permit Fee ❑X Insurance Certificate($1,000,000) ❑ Clean-Up Bond Fee(if applicable) ,. ❑X Valid Washington State Fireworks Retailer License Q Property Owners Written Permission ® Detalle e, n Q Interior Plan (required for tents and"other"facilities) I h reby c rtify th inform tion in this application is true and correct. I am aware of and agree to comply with all relevant pro ' io le y ordinance of the ate of Wa hington and the ci /county permitting this CFRS Facility. -� Z ' For Coby Treadway 0510512020 ignatur o P it Applica It For Coby Treadway Printed Name of Permit Applicant Date of Signature ITRI=_ OI] . I G >RI$171e' l0. ❑A;.P .O :ED DE II=D sE S g" to"e of e" tYig O clai ri"tedINa a aiid'Tit a Date ofS ghat e THE FIREWORKS RETAILER LICENSE HOLDER(LICENSEE)SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEM BOTH AVAILABLE FOR INSPECTION AT ANY TIME THE STAND IS IN OPERATION 3000.420.013(R 11116) FIREWORKS LEASE AGREEMENT This agreement is made between Acah Investments, LLC. Lessor and AMERICAN PROMOTIONAL EVENTS NORTHWEST as Lessee. i. American Promotional Events—NW ,will lease a portion of the property located at:(hereafter called the "Location"): Belfair Valley Plaza:..23969 State Route 3,..Beffair,WA gg§g for the sale of approved fireworks from the following premises. 2. The lease payment will be ner year for the period of June 201h thru July 7th hereafter called the "Season". Payment shall be paid on or before January 30th, 1 Lessor represents that the Location is owned and/or controlled by the Lessor and furthermore that the Lessor agrees to grant the Lessee the exclusive right to operate a fireworks sales structure (hereafter the "Structure") through the year 2020 or the above-mentioned period. 4. The Lessor herby grants Lessee a first right of refusal to match any bona fide offer to lease the Location for fireworks sales during the renewal Seasons. 5. In return, Lessee agrees to the following terms and conditions: a. Provide an A+ rated $10,000,000.00 certificate of insurance, prior to occupancy, evidencing liability insurance in force covering the erection and operation of the Structure. Insurance shall name Lessor as additional insured, and Lessor shall be held harmless from any claims arising from the maintenance or operation of the Structure. b. Pay any and all costs involved in erection, maintenance, and operation of the Structure, and Lessee shall guarantee that the Location will be returned to its original condition. c. Obtain and pay all necessary permits and licenses required by law, post with local authority any debris or performance bonds as required, and guarantee that all laws and regulations shall be adhered to. 6. This agreement is contingent upon Lessee securing necessary permits and licenses. Lessee may cancel this agreement if the sale of fireworks is prohibited at this Location by a public authority or such sale, in the good faith opinion of Lessee, becomes commercially unreasonable. In such an event any deposit shall be refunded to Lessee. Agreed to and dat this day of rt 2018 Accepted: Accepted: Lessor: Jeff ogan Lessee: Kenneth A. Spence Citation Management Group Inc. AMERICAN PROMOTIONAL EVENTS- NW Phone: 253-922-3173 AMERICAN PROMOTIONAL EVENTS, INC. 2120 MILWAUKEE WAY 9 TACOMA,WA 98421 TACOMA(253)922-0800 - FAX(263)830-2930 www.tntfireworks.com DATE(MM/DD/YYYY) AC R® CERTIFICATE OF LIABILITY INSURANCE 11/tl2o2o F-5/6/2020 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(ies)must have ADDITIONAL INSURED provisions or 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 endorsement(s). ACT PRODUCER Lockton Companies NAME: 3280 Peachtree Road NE,Suite#250 PHONE FAX A/C No): Atlanta GA 30305 E-MAIL (404)460-3600 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Everest Indemnity Insurance Company 10851 INSURED American Promotional Events,Inc. INSURER B: 1359629 DBA TNT Fireworks,Inc. INSURER C: P.O.BOX 1318 INSURER D: 4511 Helton Drive INSURER E Florence AL 35630 INSURER F COVERAGES CERTIFICATE NUMBER: 14058742 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYYY MM/DD A X COMMERCIAL GENERAL LIABILITY N N SI8GL00242-191 11/1/2019 11/l/2020 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX1 OCCUR PRE.SESOEa occur ence $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1000 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT 1XI LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT $ Ea accident XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED SCHEDULED BODILY INJURY(Per accident) $ XXXXXXX AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX AUTOS ONLY AUTOS ONLY Per accident $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE PER OTH- AND EMPLOYERS'UABILITY STATUTE ER YIN N ANY PROPRIETOR/PARTNER/EXECUTNE E.L.EACH ACCIDENT $ XXXXXXX OFFICERIMEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ XXXXXXX If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ XXXXXXX DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER,APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED. This certificate supersedes all previously issued certificate for the holder,applicable to the carriers listed and the policy term(s)referenced.Property located at Safeway Store(Belfair Valley Plaza)(IAAS5003)23960 State Route 3-Belfair WA 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 14058742 Mason County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE rth Mason Pee WeeS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN No No North on Street ACCORDANCE WITH THE POLICY PROVISIONS. Shelton WA 98584 AUTHORIZED REPRESENTA_WE /4Of ©1988=201 ACORD CORPO TIYON. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WASS003 goN co a MASON COUNTY (360)427-9670 Shelton ext.352 DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext. 352 BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext.352 Mason County Bldg. III, 426 West Cedar Street 1854 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR201-0 - w&12 soN 1 Stivee Mason County Fireworks Permit Application 6.1�\'N 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: NORTH MASON PEE WEE Mailing Address: 190 NE RAINBOW LANE City: BELFAIR State: WA Zip: 98528 Phone #: 360-551-2411 Email: coby.d.treadway@outlook.com Sponsor Information: Name: COBY TREADWAY Address: 190 NE RAINBOW LANE City: BELFAIR State: WA Zip: 98528 Phone#: 360-551-2411 Email: coby.d.treadway@outlook.com Washington State Fireworks License Information (Copy Required): License Number: G20987 Date of Issuance 05/06/2020 ❑ Pyrotechnic Operator License ® 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: SAFEWAY#1571 (BELFAIR VALLEY PLAZA)23969 STATE ROUTE 3 BELFAIR WA Directions to Site: Parcel Number: (twelve digit number}� ' l 2V q—ail-q0&z - Legal Property Owner SAFEWAY INC-ACAH INVESTMENTS "Please see reverse side to complete your application" • 1 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 t at t info a on provided herein is accurate and that compliance with all County, Federa laws pertaining to the sales or discharge of fireworks shall be main our ed Date 05/06/2020 For oby Treadway Loc No: KS date Drawn: Ordinance Address: l� city&State: Parcel No: Stand Faces The Direction : Stand Size: y . a r, a 't M Ili I 1'9il ��� uIIQIIiI��ll I� i Mason County Community Services 615 W.Alder St. Bldg 8 Receipt Number: 2020-02581 I Shelton, WA 98584 360-427-9670 ext 352 Payer/Payee: AMERICAN PROMOTIONAL EVENTS Cashier: ARIANE PAYSSE Date: 06/16/2020 NORTHWEST Payment Type: CHECK(30071466) P O BOX 1318 FLORENCE AL 35630 FIR2020-000112 Stand Application & Standards Fee Description Account Fee Amount Amount Paid Retail Fireworks Stand Permit Fee 00 1.000000.125.140 . 321.30.300030.0000.00 $100.00 $100.00 FIR2020-00012 TOTALS: $100.00 $100.00 TOTAL PAID: $100.00 Previous Related Payments Receipt • • . Amount • Total: Printed 06/16/2020 09:52:00 by Ariane Paysse Page 1 of 1