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HomeMy WebLinkAboutFIR2006-00022 Fire Works Display - FIR Permit / Conditions - 6/23/2006 i MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)127-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext.352 Shelton,WA 98584 olo FIRE PROTECTION PERMIT FIR2006-00022 APPLICANT: NORTH FORTY LODGING LLC RECEIVED: 6/13/2006 CONTRACTOR: LICENSE: EXP: ISSUED: 6/23/2006 SITE ADDRESS: 7101 E STATE ROUTE 106 UNION EXPIRES: 12/23/2006 PARCEL NUMBER: 322335000014 LEGAL DESCRIPTION: SUNNY BEACH LOTS: 10-11 & 8-9 EX ALL N OF HWY PROJECT DESCRIPTION: Fire Works Display. GENERAL INFORMATION System Information Type of Use: DIS Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 6 Hood& Duct?: Flow Switches: Visual Devices: Door Releases: Dry Chemical?: Pressure Switches:: Smoke Detectors: Duct Detectors: Wet Chemical?: Zones: Heat Detectors: Sprinkler?: Standpipe?: SQUARE FOOTAGE FEES Monitoring Company. FirstFloor: Monitoring Phone No.: -Q Second Floor: Type Amount Due Amount Paid Auto Fire Alarm?: Third Floor;: Fireworks Display Permit $132.50 $132.50 Total: $132.50 $132.50 FIR2006-00022 Please refer to the following pages for conditions of this permit. 1 of 3 CASE NOTES FIR2006-00022 CONDITIONS FOR FIR2006-00022 1.) Site inspection by the Fire Marshal s 'ir prior to discharge of the display. Contact the Fire Marshal @ 360-427-9670 ext 273 by June 30th to schedule an inspection time. X. Mason County Fire District#6 will be on andby with attached but dry supply and attack lines and have a boat in the water. X This permit becomes null and void if work or construction authorized 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. Evidem ork is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied.Proof of continuation ofwork is by means ofa progne orthe agent on the owners behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described property d inspection. OWNER OR AGEN DATE: - 23-6l0 r FIR2006-00022 Please refer to the following pages for conditions of this permit. 2 of 3 N CONCRETE MECHANICAL MANUFACTURED HOME O Gate By O Footings t Setbacks Ribbons � Gas Piping = CInleriof Date By interior-Date By Date By T CD Extef" Date By Exterior-Date By �-�p O N -- ---- INSULATION tV Point Load!Isolated Footings Date By pate By BG l SLAB INSULATION � Data By FIRE DEPARTMENT Foundation Walla Floors Date By Q Date By Data By +n DECKS Z FRAMING Walls Date By O Datek, Data By PROPANE TANKS r- PLUMBING vault Date ay n Date By OTHER . Groundwork Attic Date By pate By Type_Date By D.1N:v DRYWALL _._ Type, Int Brace Wall Date B ©ate By y Date By FINAL INSPECTION N (D Water Line Fire Separation C Date By Date By Date, By C) �D O CD o Pass or Request Inspect. Co Type of Insp. Fail Date Date Done By Comments tl i 0 0 3 O tQ O n O 3 a 0 y O f/1 3 w 0 w z Mason CountyM PA�WA Z Fireworks Permit Application PO BOX 186 Permit # FIR.k'o� ' _- 426 W Cedar St Shelton WA 98584 Receipt # S z2-zdn - ('bj (360) 427-9670 ext 273 CK # Z2- Date Received A Permit for the 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 Marshail. Applicant Information Name: Entertainment Fireworks, Inc. J Mailing Address: Po Box 7160 v City: olympij�' State: WA Zip: 98507-7160 Contact Number (360 ) 5 -B 11 Sponsor Information Name: Alderbrook Resort & Spa Mailing Address: 10 E. Alderbrook Dr. , City: union State: WA Zip: 98592 _ Contact Number (360 )898-5527 Washington State Fireworks License Information (Copy Required) License No.: C-04085 Date of 2/2/06 Issue: ❑x Pyrotechnic Operator License ❑ Fireworks Stand License j Aaron Kul — ------— ---- Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: See Attached Insured: Certified Holder: Location of stand/display Address- 7101 F. StatpRoy 106 Union - Alderbrook Resort & Spa _ Directions to Site: Take Hwy. 16 West to Gorst , then go South on HwW 3 p Bel fai . South of Belfair turn right on Hwy 106 & Go 15 miles to Alderbrook _ Parcel Number: - - 322335000014 _ Legal Description: Sunny Beach Tr 8-11 EX and Tax 895 See SP # 1664 _ Legal Property Owner: * * Please see the reverse side to complete your application � 1 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 4or designated display areas to: • Fire Hydrants • Property Lines • Buildings • Parking • Combustibles • Public Roads and Right of Warys • 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 Date FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: ACORQ. CERTIFICATE OF LIABILITY INSURANCE 3/21(/2/D) 6') PRODUCER Phone: 440-248-4711 Fax: 440-248-5406 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cleveland OH 44139 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Lexington Insurance Co Entertainment Fireworks, Inc. INSURERS: Granite State Insurance Co. P. O. Box 7160 Axis Surplus Ins Company Olympia WA 98507-7160 INSURERC: P P Y 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 DO' POLICY EFFECTNE POLICY EXPIRATION T POLICY NUMBER LIMBS A GENERAL LIABILITY 7410471 2/15/2006 2/15/2007 EACH OCCURRENCE $ 1,000,000 X AMAG TOREN D 50,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ CLAIMS MADE a OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,0 0 0,0 0 0 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,006,000 POLICY X PRO- LOC JECT B AUTOMOBILE LIABILITY CA 6 2 6 5 8 5 2 3 2/15/2 0 0 6 2/15/2 0 0 7 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1, 000, 000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident) PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHERTHAN AUTOONLY: AGG $ C EXCESS/UMBRELLA LIABILITY EAU7 0 S 9 7 8 2/15/2 0 0 6 2/15/2 0 0 7 EACH OCCURRENCE $ 1,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 1,000,000 $ RDEDUCTIBLE $ X RETENTION $ 10, 000 $ WC STATU- OTH- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY T RYLIMITS ANY PROPRIETORMARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L DISEASE-EA EMPLOYEE $ S yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Date of Display: July 2, 2006. Location: End of stationary dock at Alderbrook Resort. Addl. Insureds: Alderbrook Resort & Spa, North Forty Lodging LLC, Jeffrey & Patricia Raikes, Mason County, 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 Alderbrook Resort & Spa BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER P WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 10 E. Alderbrook Drive CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Union WA 38592 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATqI�VES. AUTHORIZED REPRESENTATIVE ACORD 25(2001108) ©ACORD CORPORATION 1988 ® � t 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. ACORD 25(2001/08) viiloiuc ntll 10:v0 rAA 1 :r0u 4ZU 6547 MASON CO PUD MAIN IQ 002 116Capt[olWay N, , CLIENT +�� ZQi1Gj ATE Olympia.WA 98501 \/1 b/p 360,943.3556 360.943.2140 fax www.capiiolcirypress.com Capitol Cit� PRES SR - - - f _ ; e —_- - — i o� .#0(— I _ . �`' c..v co � . v 0 E IV FIR i _. . LEG or f S: 00 ; ' � 1 • — (. ; I i I I j I 1 �,Vasttington .State Patrol Fire Protection Bureau Orrice Of The.State Fire Marshal 1'�t'ntechitic�perator Aaron Scott Kulp License Number P-04241 !!PLO—f L i u n,se: Pyrotechnic Operator Kx2ir;iti0n DatL January 31, 2007 I ashington State Patrol Fire Protection Bureau Office Of The State Fire Marshal Washington State fireworks Licell su Importer License w Importer: Entertainment Fireworks, Inc. Post Office Box 7160 Olympia, WA 985077160 Washington State Patrol Fire Protection Bureau Office Of The State Fire Marshal Washington State Fireworks LAcenlse NN' holesalei License Washington State Patrol Fire Protection Bureau Office Of The State Fire Marshal WashinVton State Fireworks License General Display .License (�cncra) Display: Entertainment Fireworks-General Display Post Office Box 7160 Olympia, WA 985077160 i h t,ich ti,is wallet card and earn-N,t!, %(_,u 6o verification ofcerttticatton In-State Representative: J. Larry Mattingly �N ashington State Patrol y t'ire Protection Bureau A, Phone Number: (360) 5316- ')09 Offiicr Of The Statc fire Marshal (,eneral llisplaN: Entertainment Fireworks-(icne Imense Number: ('-O408', Date of Issue' F.�piration I)atc Licc tts( tiumher Tyne of 1 tcew e: (iener�il I�i�hl.ty February 2, 2006 January 31, 2007 1-108j Phone Number: (,00) 5_,6-5109 Expiration Pate: lanuary i 1, 2007