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HomeMy WebLinkAboutFIR2022-00030 Fireworks Stand - FIR Inspections - 6/10/2022 Inspection Card Mason County 615 W. Alder St. Bldg. 8, Shelton, WA 98584 (360) 427-9670 ext 352 www.co.mason.wa.us PERMIT# FIR2022-00030 PROJECT ADDRESS 23967 NE STATE ROUTE 3 BELFAIR, WA 98528 PARCEL# 123294190022 PROJECT DESCRIPTION FIREWORKS STAND FOR NORTH MASON PEE WEE OWNER NORTH MASON PEE WEE ADDRESS PHONE INSPECTION I INSP DATE COMMENT FIREWORKS INSPECTION CONDITIONS (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. * (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. (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. ` (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. " (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. (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. * (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. 7 t � WASS003 PS0 Cot, 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 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 2Z - 60030 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: NORTH MASON PEE WEE Mailing Address: 291 East Mountain View Dr. City: Allyn State: WA Zip: 98524 Phone #: 360-551-2411 Email: coby.d.treadway@outlook.com Sponsor Information: Name: COBY TREADWAY Address: 291 East Mountain View Dr. City: Allyn State: WA Zip: 98524 Phone#: 360-551-2411 Email: coby.d.treadway@outlook.com Washington State Fireworks License Information (Copy Required): License Number: G22856 Date of Issuance April 8,2022 ❑ 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) - - la3�g - OOa"ol Legal Property Owner SAFEWAY INC -ACAH INVESTMENTS **Please see reverse side to complete your application** s 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 n- 1Oyu - Date June 10, 2022 For Coby Treadway w; WASS003: Safeway #1571 M 23961 NE State RT 3 STAND Belfair WA, 98528 LOCATION TYPE: STAND 32' CONTAINER �111r° J. i�l e To 488' v ��A ljr� Tee` "F '�l t4+ � ..wf�•. i r <, k Mason Co. WAS5003 THIS FORM IS INTENDED FOR USE BY LOCAL AUTHORITIES HAVING JURISDICTION(AHJ)IN THE EVENT THEY DO NOT HAVE A PERMIT FORM SPECIFIC FOR RETAIL FIREWORKS SALES AT A CONSUMER FIREWORKS RETAIL SALES(CFRS)FACILITY. IT IS NOT MEANT TO BE REQUIRED IN ADDITION TO OR IN LIEU OF ANY LOCAL PERMITTING FORMAND/OR PROCESS THAT MAY EXIST WITH THE LOCAL AHJ. Directions: Provided the local jurisdiction has no permit form of their own,complete this permit application and submit it with the local AHJ portion of your Retail Fireworks Stand License to the jurisdiction in which you wish to run your CFRS facility. WASHINGTON STATE FIREWORKS RETAIL SALES PERMIT APPLICATION Applicant Information ❑ New/First Time Applicant IN Previous Permit Holder North Mason Pee Wee Name of Group,Organization,or Person(Last,First,Middle Initial,and Date of Birth)Issued the Fireworks Retailer License Coby Treadway Name of Permit Applicant(Last,First,Middle Initial,and Date of Birth) 2120 Milwaukee Way - Tacoma Washington 98421 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 X❑ Stand ❑ Tent Other: Size: 8 X 32 = 256 sq. ft. Specify Square FeeVDimensions Safeway #1571(Belfair Valley Plaza) 23969 NE State Route 3 Belfair, Wa 98528 CFRS Facility Address(Complete Including Street,City,State,and ZIP Code) Safeway Inc./Acah Investments { ) 10-06180 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 Storage Information ❑X On Site ❑ off site: At the stand with security Storage Address(Complete Including Street,City,State,and ZIP Code) ❑X Sales Structure ❑ Detached Building ❑ Truck/Trailer ❑ Other: Specify CHECKLIST FOR SUBMISSION Check with the local AHJ for all applicable submission dates and deadlines: © ApplicationlPermit Fee 0 Insurance Certificate ($1,000,000) ❑ Clean-Up Bond Fee(if applicable) © Valid Washington State Fireworks Retailer License ® Property Owners Written Permission IN Detailed Site Plan Fx_] interior Plan (required for tents and "other"facilities) I hereby certify the information in this application is true and correct. I am aware of and agree to comply with all relevant rovisions of law, rule, and any ordinance of the state of Washington and the city/county permitting this CFRS Facility. For Coby Treadway YYs` l ��UL Ronda Johnson- Dove June 10, 2022 Signature of Permit Applicant Printed Name of Permit Applicant Date of Signature .fx wr'w r ,,;c ` '`' ✓,a ,� J $ ` why` /"''" a✓, �,`r r� r f f FIRE CODE AUTHORITY�HAVING JURISDICTION ❑APPROVED r❑ DENIED F r��f ,.......,:w:....,..cc, ✓�;,.�;. ..:..,vr..r?r.�.ai..n:..�r.�...wF;�r',>;,fx.,'.../r.. .,Y.�-:,, ,...f..,::� ......,<„ „�,' -^ �r�✓ :.,...f. 1""NS`r L k' L� fI a^`J( �,iJ "� Y rr",/f Sl �NrYSi Tc-Ml YC,✓ eS' �Y f. .Jr f ��4s 1._ Y OU J�.. 10 F ,.u-F -�,y- v,,,�' *1' `� ✓�'���.,,r ,�.� � ,C-� � r v- � <k-✓, r� G` ,� ✓ `�:f �`-J- 1�,.., f„ :/ �- L- .a - .mac�J`r-..:� '',�"` c .x--x .�r-" r"'.`,G aw`�r�.. ✓may,c,: f f ` .� h r'ti.....7' .r t, r'. 'k^ c. <`' .: �k�� Pe�rtltltymbe ,� ' r ApProvedBy �� ��y Date of Approval �..�,,` a, ~ �:� ''r `'F. •/CS k*,w „.'<r 'ter' ^. <Y -'g".#'�-,.✓" P r' 5 u t �.r✓ r emu' .n �.,. SEE BACK OF TIIS FORM FOR ANYyRESTRICTIOVS CONDITIQNS, OR NOTATIONS ON TF(!S REftMITF ' - - ,.crn«G.e,�1„k �, .,h.�.<yz�+,,.o,<..�;c�'�. ,qzt k :.ry r \ .k v`^4 t`�ff ' 'a'�'�x b. `'� ;✓'G..-e^..r` -� �,���,<. F:CvC':Y'v„'�.-'..Ss-: ,=��5;rt}S.G=rp!,{�o-l+' :,.' �'F- y 1 r l✓'j ,c/�, :."OS y, �' .N..-�: .J �+'. F.'.:Y'.^;'3-s�4. -°"..J^4�.'".'`� f..rr.: f S- .k. f' '` ,/".. 3.1 ,`:r "s` ',1��;... .rS:✓,...,...f .1': � .,C (4 'Z oG!. "..,,,rnu�� :..�'.� �.,e�t�, c�a..r��. �?r�'�iz. 2-.. 'arp✓,.,�•^"v C.ua:�.!�i� '.a ����.�v:. .� fir(<f a r`1 „'`r :�.�r'y<,dv.:.�-�j� �-:a�-��ssu' ,.'.^a4, �r_ THE FIREWORKS RETAILER LICENSE HOLDER(LICENSEE)SHALL RETAIN THIS PERMIT WITH THE ASSOCIATED FIREWORKS RETAILER LICENSE AND MAKE THEM BOTH AVAILABLE FOR INSPECTION AT ANYTIME THE STAND IS IN OPERATION 3000-420-013(R 11116) WAS5003 FIREWORKS LEASE AGREEMENT This agreement is made between Acah Investments, LLC Lessor and AMERICAN PROMOTIONAL EVENTS NORTHWEST as Lessee. 1. American Promotional Events—NW, will lease a portion of the property located at:(hereafter called the "Location"):: Belfair Valley Plaza: 23969 State Route 3, Belfair,WA 98528" the sale of approved fireworks from the following premises. 2. The lease payment will be ear for the period of June 201h thru July 9th hereafter called the "Season". Payment shall be paid on or before January 30" 3. 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 2023 or the abovementioned 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 dated this 23 day of 71, Accepted: Accepted- Lessor: Jeff Hogan Lessee: meth A. Spence Acah Investments, LLC AMERICAN PROMOTIONAL EVENTS—NW 5312 Pacific Hwy E. Fife, WA 98424 Phone: 253-922-3173 AMERICAN PROMOTIONAL EVENTS, INC. 2120 MILWAUKEE WAY • TACOMA,WA 98421 TACOMA(253) 922-0800 • FAX (253)830-2930 www.tntfireworks.com DATE(MM/DD/YYYY) ACC>® CERTIFICATE OF LIABILITY INSURANCE llili2o22 T24/2022 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 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). CONTACT PRODUCER LOCkton Companies NAME, 3280 Peachtree Road NE,Suite#250 PHONE FAX Atlanta GA 30305 -MAIL o.Ext: A/C No (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 COVERAdW1001 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. INTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM DDPOLICY/YYYY MM DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY A X Y N SI8GL00242-211 11/1/2021 11/1/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE Fx_] OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PE LOC PRODUCTS-COMP/OP AGG $ 21000,000 OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT $ Ea accident XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX OWNED SCHEDULED t BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS XXXXXXX HIRED NON-OWNED PROPERTY DAMAGE $ XXXXXXX AUTOS ONLY AUTOS ONLY Per accident $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB HCLAIMS-MADE AGGREGATE $ XXXXXXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ XXXXXXX OFFICER/MEMBER 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 $ XXXXXXX . . .............................7 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. Property located at Belfair Valley Plaza 23960 State Route 3,Belfair,WA 98528(WAS5003) 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 North Mason Pee Wees THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 411 North Sth Street ACCORDANCE WITH THE POLICY PROVISIONS. Shelton WA 98584 AUTHORIZED REPRESENTATIVE ©198E-20116 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD GTOM gT410 Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal G22856 W CONSUMER FIREWORKS RETAIL SALES (CFRS) FACILITY LICENSE BSMAVS GEC` Stand Number: SN-14761 Licensee Data Operational Data American Promotional Events, Inc. - West Wholesaler: American Promotional Events, Inc. - WE 2120 Milwaukee Way County of Operation: Mason Tacoma, WA 98421 Operates For: NORTH MASON PEE WEE License Number: WSPFL-02766 Stand Operated By: COBY TREADWAY Phone Number: (253) 922-0800 Date of Issue:April 8, 2022 Date of Expiration:January 31, 2023 Consumer Fireworks Retailer Licenses issued after May are ONLY valid for New Years Sales This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single location/stand for retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler. THIS LICENSE PORTION ACCOMPANIES YOUR LOCAL PERMIT APPLICATION WAS5003 3000-420-041(10/18)