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HomeMy WebLinkAboutFIR2005-00028 - FIR Permit / Conditions - 6/2/2005 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext.352 Shelton, WA 98584 FIRE PROTECTION PERMIT FIR2005-00028 APPLICANT: ENTERTAINMENT FIREWORKS, INC RECEIVED: 6/2/2005 CONTRACTOR: LICENSE: EXP: ISSUED: 6/23/2005 SITE ADDRESS: 271 E OKONEK RD GRAPEVIEW EXPIRES: 12/23/2005 PARCEL NUMBER: 121082400060 LEGAL DESCRIPTION: TR 6 OF G. L, 2 & TAX 652-D & 652-AlA PROJECT DESCRIPTION: FIREWORKS DISPLAY GENERAL INFORMATION System Information Type of Use: STND Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 5 Hood & Duct?: N Flow Switches: Visual Devices: Door Releases: Pressure Switches:: Smoke Detectors: Duct Detectors: Dry Chemical?: N Zones: Heat Detectors: Wet Chemical?: N Sprnkler?: N Standpipe?: N SQUARE FOOTAGE FEES Monitoring Company: First Floor: Type Amount Due Amount Paid Monitoring Phone No.:0- Second Floor: Auto Fire Alarm?: Third Floor;: Fireworks Stand Permit $132.50 $132.50 Total: $132.50 $132.50 FIR2005-00028 Please refer to the following pages for conditions of this permit. 1 of 3 CASE NOTES FIR2005-00028 CONDITIONS FOR FIR2005-00028 1.) Site inspection by the Fire Marshal is ui o discharge of the display. Contact the Fire Marshal @ (360)-427-9670 ext 273 before July 1st to schedule an inspection time. X "This permit becomes null and void if work or construction auth rized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at any time after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied. Proof of continuation of work is by means of a progress inspection.The ownerorthe agent on the o ners behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure for review d ins OWNER OR AGENT: _ t DATE: ; FIR2005-00028 Please refer to the following pages for conditions of this permit. 2 of 3 Mason County Fireworks Permit Application PO BOX 186 Permit # FIR=� - 426 W Cedar St ��� a3' .M gZl6helton WA 98584 Receipt # _QJJ 0 11S V4 (360) 427-9670 ext 273 500Z �, CK # 12 Date Received mit for t Retai r Public display of fireworks is required. A completed application with ired 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 Name: Entertainment Fireworks, Inc. Mailing Address: Po Box 7160 City: Olympia State: WA Zip: 98507-7160 Contact Number (360 ) 352-8911 Sponsor Information Name: Grapeview Community Patriotic Celebration Mailing Address: 6945 NW Illich Road City: Silverdale State: WA Zip: 98383 Contact Number ( 360 ) 476-8773 Washington State Fireworks License Information (Copy Required) License No.: C-04085 Date of 1-20-05 EntPrtai nment Fireworks, Inc-,ISSue: ® Pyrotechnic Operator License ❑ Fireworks Stand License Christopher Williams #P-004036 Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: See Attached Insured: Certified Holder: Location of stand/display Address: Offshore from E271 Okonek Road, Grapeview WA Directions to Site: Middle of Bay near Stretch Island Parcel Number: 1a106 - - OOd(.00 Legal Description: Te- Lp o L £ T►4X w 5a-0 � to 5a - 14(,4 Legal Property Owner: l; * * Please see the reverse side to complete your application The following pertinent information MUST be provided on the site diagram below Locations and Setback distances from the back, sides and front of retail sales stands or designated display areas to: • Fire Hydrants • Property Lines • Buildings • Parking • Combustibles • Public Roads and Right of Ways • Fire Lanes • Private Roads and Right of Ways • Trees/Brush • Landmarks • Utilities and Gas • Mortar separation distance • Designated landing area 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 �,_cnaaA A , Ad, Date F R OFFIJ20L ONLY BELOW THIS LINE Accepted By: Date: k ®m croH sr� APPLICATION DATE OF APPLICATION _ ��� ,j" ,�J® FOR PUBLIC FIREWORKS DISPLAY PERMIT a13-D.S t TO: Governing body of city,town or county in which display is to be conducted. �/caDoS' cook 8 APPLICANT NAME ADDRESS PHONE Entertainment Fireworks, Inc. PO Box 7160 Olympia WA 98507-7160 360-352-8911 t SPONSOR ADDRESS PHONE P Gra eview Community 6945 NW Illich Rd. , Silverdale WA 98383 360-476-8773 PYROTECHNIC OPERATOR NAME ADDRESS 57 N Re bud , B e erton 8311 LICENSE# Chris Williams X� �t �� P-004036 NAMES OF ASSISTANTS: at least one required) NAME ADDRESS AGE Charles Wilson 4071 Chico Way, Bremerton WA 98312 Legal NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION pz�Q 000coD Middle of Baynear Stretch Island Offshore from E27 Okonek Road Gra eview WA DATE TIME July 4 2005 1 Dark Approx 10:00 PM NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED 3.0" Salutes - 10 3.0" Comets - 4, 2.0" Roman Candles - 4 Multi-shot Cake Devices up to 3.0" - 6, 2.5" Aerial - 15, 3.0" Aerial - 50 4.0" Aerial - 40, 5.0" Aerial - 16 MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) Delivered to site day of display. SIGNATURE OF APPLICANT - eJLsi FINANCIAL RESPONSIBILITY BONDING OR INSURANCE CO. (Mark One) Britton Gallagher & Associates ® Bond or certificate of insurance attached Bond or certificate of insurance on file with State Fire Marsha ADDRESS Bond or certificate of insurance shall provide minimum 6240 SOM Center Rd. Cleveland OH 44139 coverage of$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 this permit is granted to conduct a fireworks display as per the above application. � l NAME 4 r (Full name of person,firm or c rporation granted permit) LJ !V 0 RESTRICTIONS: W LJ V 3 5'r7-A— /N6 'c�7-7d-,L) Q10 vi2� '• N nature ot6ffical gra/- i permit) Permit not valid without verification of State General Display License (Title) LICENSE NUMBER C-04085 (Instructions on reverse side) Distribtuion: WHITE(A): Local Fire Authority; YELLOW(B): State Fire Marshal's Office; PINK(C): Permitee 3000-420-050(R 01/01) INSTRUCTIONS APPLICANT Complete Part I of the application and present all three copies to the Chief Fire Official of the city, town or county in which the display is to be held. If a Special Public Display License is contemplated,attach documentary proof of a surety bond or a certificate of public liability insurance covering the time period of the display. If the applicant already has a General Display License for displays at various locations,indicate that a bond or certificate of insurance is on file with the State Fire Marshal,covering the date and location of the display. General Public Display Licensees retain Copy"C"of the comptleted application and return Copy"B"to the State Fire Marshal's office,210 11 th Avenue SW, Post Office Box 42600,Olympia,WA 98504-2600. If not already in possession of a General Public Display License, forward copes"B"and"C"along with the$10,00 Special Display License fee,to the State Fire Marshal's office. Upon receipt by the State Fire Marsha's office,the license of the Pyrotechnician will be verified and a Special Public Display License issued. Copy"C"and the license will be returned to you,which will authorize the purchase of the special fireworks listed on the application. Copy"C"shall be maintained at the display site and made available to local or state officials to verify the Permit and License. CHIEF FIRE OFFICIAL/GOVERNING BODY Determine that the applicant is in possession of a current State Public Display license,and that the Pyrotechnician holds a current State Pyrotechnicians license. Make an investigation of the proposed site to determine whether the display will be hazardous to property or dangerous to life. Exercise reasonable discretion in evaluating fire hazards,vehicle parking,crowd control,storage prior to display and general precautions against fire, explosion or panic during the display. (Use of NFPA 1123 Public Display of Fireworks is recommended for guidelines.) Submit your findings and recommendations to the governing body for final decision or, in the the event that htis authority has been delegated to you,issue or deny the permit. If approved,the governing body or fire official should complete Part II of the Application and retain Copy"A"plus the documentary proof of insurance,and return the othercopies"B"and"C"of the Application to the applicant. FIREWORKS WHOLESALER Possession by the applicant of Copy"C"of the completed Application,signed by the local issuing authority along with the license issued by the State Fire Marshal,shall serve as authorization to the wholesaler to sell the applicant the Special Fireworks listed on the Application,for use at the date and location specified. The Pyrotechnician's report,required to be filed by the pyrotechnician within ten days following the display,will be retained by the State Fire Marshal,along with Copy"B"of the application,as evidence of the display. RCW 70.77.285. FILING SURETY BOND OR CERTIFICATE OF INSURANCE. The applicant for a public display of fireworks permit shall at the time of the application,file with the officer to whom the application is made,a bond issued by an authorized surety company to be approved by such officer,conditioned upon the applicant's payment of all damages to persons or property which shall or may result from or be caused by such public display of fireworks,or any negligence on the part of the applicant,or their agent,servants, employees,or sub-contractors in the presentation thereof,or a certificate of insurance evidencing the carrying of appropriate public liability insurance for the benefit of the person named therein as assured,as evidence of ability to respond in damages in at least such amount,said policies to be similarly approved. RCW 70.77.295. AMOUNT OF BOND OR INSURANCE. In the case of an application for a permit for the public display of fireworks,the amount of such a surety bond or certificate of insurance shall be not less than fifty thousand dollars and one million dollars for bodily injury liability for each person and event, respectively,and not less than twenty-five thousand dollars for property damage liability for each event. RCW 70.77.355. ALTERNATIVE PROVISIONS FOR GENERAL LICENSEES. (1)Not withstanding any of the other provisions of this chapter relating to public liability insurance and bonds,any adult individual,concern,firm, corporation or co-partnership may secure a general license for the public display of fireworks within the state of Washington subject to the - provisio,is of this chapter relative to the securing of local permits for the public display of fireworks in any city or county,except that in lieu of filing the bonds or certificate of public liability insurance as required in RCW 70.77.285 and 70.77.295,a surety bond similarly conditioned or a certificate evidencing public liability insurance in a like amount shall be filed with the State Fire Marshal. The bond or certificate evidnencin> publtq, libility of insurance in a like amount shall provide that:(a)the insurer wil not cancel the insured's coverage without fifteen days prior written notice to the State Fire Marshal; (b)the duly licensed pyrotechnic operator required by law to supervise and discharge the public display,acting either r as an employee of the insured or as an independent contrator and the State of Washington, its officer,agents,employees and servants are included as additional insured,but only insofar as any operations under contract are concerned;and(c)the state is not responsible for any,, premium assesments on the policy. (2) The State Fire Marshal shall have the authority to issue such licenses,subject to such reasonable rules and regulations which he or she may adopt,not inconsistent with the provisions of this chapter. A certificate evidencing such general license,when so obtained,shall be filed with the legislative body or officer granting a permit for the public display of fireworks prior to the issuance thereof. ACORD,M CERTIFICATE OF LIABILITY INSURANCE 3/7/(2005YYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton-Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cleveland OH 44139 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED i INSURER A: Lexington Insurance Co Entertainment Fireworks, Inc. INSURERB: Granite State Insurance Co. P. 0. Box 7160 Olympia WA 98507-7160 INSURERC: INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR POLICY NUMBER DAT M DD Y ATE MM D Y LIMITS A X GENERAL LIABILITY 2831366 2/15/2 0 0 5 2/15/2 0 0 6 EACH OCCURRENCE $ 1,000, 000 COMMERCIAL GENERAL LIABILITY DAMAGETO RENT 550,000 PREMISES Ea occurence $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC B AUTOMOBILE LIABILITY CA62658522 2/15/2005 2/15/2006 COMBINED SINGLE LIMIT $ 1,000, 000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- WORKERS COMPENSATION AND T 1 T EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L DISEASE-POLICY LIMIT I$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Date of Display: Jul 4, 2005. Location: Off West shore of Stretch Island at E 271 Okonek Rd., Grapeview. Addl. Insureds: Grapeview Comm. Patriotic Celebration, Mason County, Mason Cty Fire Dept., their officers, agents, and employees when acting in their official capacity as such. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER Grapeview Comm. Patriotic Celebration WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE C/O Mazanti CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO PO BOX 468 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Grapeview WA 98546 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) 0ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 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