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HomeMy WebLinkAboutFIR2019-00021 - FIR Permit / Conditions - 6/19/2019 ` PgON co�Nrf 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 1 0002 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: Alderbrook Resort & Spa Mailing Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone #: 360.898.2252 Email: cindy.sund@alderbrookresort.com Sponsor Information: Name: Alderbrook Resort & Spa Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone #: 360.898.2252 Email: cindy.sund@alderbrookresort.com Washington State Fireworks License Information (Copy Required): License Number: P-04311 Date of Issuance ? see attached Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: The Partners Group, Ltd. Insured: Wolverine West, LLC Certified Holder: Alderbrook Resort & Spa Location of Stand/Display: ID 6 ` 61 clUt= Site Address: 7101 E WA-106, Union, WA 98592 Directions to Site: see attached Parcel Number: (twelve digit number) - - Fired an Puget Sound Legal Property Owner n/a a3i A'3 66 1 "Please see reverse side to complete your application" 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 aerial 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 6/19/19 i _ PART I ® "" APPLICATION DATE OF APPLICATION tU FOR PUBLIC FIREWORKS DISPLAY PERMIT 6/19/19 • TO: Governing body of city, town, or county in which display is to be conducted. APPLICANT :,..:., - . . ... .n NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E WA-106, Union WA 98592 360.898.2252 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Webb 5030 180th Trail SW, Rochester WA 98579 j P-04311 i NAME OF ASSISTANTS: at least one required) NAME ADDRESS AGE Herb Harris 2115 9th Ave SW Apt F2, Olympia WA 98502 P-04312 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION it Puget Sound in front of Alderbrook Resort, 7101 E WA-106, Union WA 98592 DATE 7/3/19 TIME 10:15pm+/- NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED [222] 3" shells - [132] 4" shells - [69] 5" shells - [36] 6" shells - [3] cakes Aaron Webb cell: 360.790.3409 it I MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines 12 , i SIGNAT E OF APPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) The Partners Group © Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 11225 SE 6th St., Suite 110 Bond or certificate of insurance shall provide minimum coverage of Bellevue, WA 98004 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II PERMIT PERMIT# DATE: li 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. NAME: (Full name of person,firm,or corporation granted permit) RESTRICTIONS: II, Permit not valid without verification of (Signature of Official granting permit) the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW (B): Permitee II -- ACOOR" CERTIFICATE OF LIABILITY INSURANCE 76/19/2019 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 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). PRODUCER CONTANAME: Janet Nau The Partners Group Ltd PHONE FAX D 11225 SE 6th St., Suite 110 A o •425-455-5640 A/c No:425-455-6727 Bellevue WA 98004 ADDRESS: inau@tpgrp.com INSURERS AFFORDING COVERAGE NAIC S INSURER A:T.H.E.Insurance Company 12866 INSURED 15539 INSURER B:Alaska National Ins CO Wolverine West, LLC DBA Wolverine West Fireworks INSURERC: PO BOX 628 INSURERD: Chehalis WA 98532 -INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:206175630 REVISION NUMBER: 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. ILTR POLICY EXP TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DDDPOLICY EFF MM DD/YYYY LIMITS LTRWVD A GENERAL LIABILITY Y CPP010545603 5/1/2019 5/1/2020 EACH OCCURRENCE $1,D00,000 X COMMERCIAL GENERAL LIABILITY AMAVE RENTED PREMISESS Ea occurrence E 100,000 CLAIMS-MADE FX]OCCUR MED EXP(Any one person) $0 PERSONAL&ADV INJURY $1,000,OD0 GENERAL AGGREGATE $10,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY CPP010545603 5/1/2019 5/12020 COMBINED SINGLE LIMIT Ea accident 1,1300,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident) $ $ A UMBRELLA LIAB X OCCUR ELP001218203 5/1/2019 5/12020 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,D00,000 DED RETENTION$ GL ONLY $ B WORKERS COMPENSATION 18FWU09079 6/242018 6242019 X I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,D00,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,Ooo,000 A Auto Excess Liability ELP001218303 5112019 5112020 Each Occurence 4,000,000 -Occurrence Aggregate 4.000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Certificate holder is included as Additional Insured on General Liability as their interest may appear as respects operations performed by or on behalf of the Named Insured,as required by written contract. Alderbrook Resort&Spa,Mason County&its employees ATIMA are Additional Insured as respects the 7/3/19, 11/22/19, 12/31/19 Aerial Fireworks Displays located at Alderbrook Resort&Spa,7101 E State Highway 106,Union,WA 98592. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Alderbrook Resort&Spa 7101 E State Highway 106 Union WA 98592 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD