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Home My WebLink AboutFIR2005-00027 - FIR Permit / Conditions - 6/27/2005 Mason County Fireworks Permit Application PO BOX 186 Permit# FIR Q - 426 W Cedar St Shelton WA 98584 Receipt # (360) 7-9670 ext 273 Date Received 5 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 Marshal. Applicant Information Name: Entertainment Fireworks, Inc Mailing Address: Po Box 7160 City: State: wA Zip: a85n7-716n Contact Number (360 :352-891 1 Sponsor Information Name: North Fourty ventures Mailing Address: 22526 SE 64th PL, suite 210 City: Issaquah State: wA Zip: 98027 Contact Number (4;r-)-3699290 Washington State Fireworks License Information (copy Required) License No.: c-04085 Date of 1/20/05 Issue: ® Pyrotechnic Operator License ❑ Fireworks Stand License -] P-004117 Jay Himlie Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: See Attached Insured: Certified Holder: Location of stand/display Address: 7101 E. State Route 106 Union - Alderbrook Inn Directions to Site: Take Hwy. 16 west to Gorst, then go south on Hwy. 3 to Belfair. South of Relfair turn right on Hwy 106 and go 15 miles to Alderhro k Parcel Number: - - 322-135000014 Legal Description: Sunny Beach Tr 8-1 1 Ex and Tax 895 See SP #1664 Legal Property Owner: * * Please see the reverse side to complete your application The following pertinent information MUST be provided on the site dia ram 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 0 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. `n' AJ, Signed � y (n Date ,_- / C FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: ®®�® APPLICATION DATE OF APPLICATION ' PART I J ® FOR PUBLIC FIREWORKS DISPLAY PERMIT TO: Governing body of city,town or county in which display is to be conducted. -APPLIdANT NAME ADDRESS PHONE Entertainment Fireworks, 1nc. PO Box 7160 Olympia WA 98507-7160 360-352-8911 SPONSOR ADDRESS PHONE North Fourty Ventures 22526 SE 64th PL, Suite 210, Issaquah WA 98027 425-369-9290 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Jay Himlie 12365 SE Arcadia RD, Shelton WA 98584 IP-004117 NAMES OF ASSISTANTS: at least one re uired NAME ADDRESS AGE Michelle Himlie 2365 SE Arcadia RD, Shelton Wa 98584 Legal NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION from stationary dock at Alderbrook Inn, 7101 E. St Rt 106 Union, in Mason Cty #3223350000 DATE TIME July 3, 2005 1 Dark Approx 10:00 PM NUMBER AND KI DS OF FIREWORKS TO BE DISPLAYED 2.0" & 3.0" Salutes - 15, 2.0" & 3.0" Comets - 22, 3.0" & 4.0" Mines - 12, Roman Candles up to 2.0" - 14, Multi-shot Cake Devices up to 3.0" - 3, 2.5" Aerial - 20, 3.0" Aerial - 130, 4.0" aerial - 140, 5.0" Aerial - 12 MANNER 8L PLACE OF STORAGE PRIOR TO DISPLAY Sub'ect to approval of Local Fire Authority) Delivered to site day of display. SIGNATURE OF APPLICANT 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# / //7 2ax-l� 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. NAME of (Full name of person,firm or corporation granted permit) 4 0 W RESTRICTIONS: U 3 Ignature of O ranting p r it) Permit not valid without verification of State General Display License EI- (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 - v provisions 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 7 P Y q 0.77.285 and 70.77.295,a surety bond similarly conditioned or a certificate evidencingpublic liability insurance in a like amount shall be filed with t P Y he State Fire Marshal. The bond or certificate evidnencin9public' Iibility 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 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. L DATE(NWODNY" ACORD, CERTIFICATE OF LIABILITY INSURANCE 3/17/2005 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION pritton-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 INSURERA: Lexington Insurance Co Entertainment Fireworks, Inc. INSURERS. Granite State Insurance Co. P. 0. Box 7160 INSURERC: Axis Specialty Ins Company Olympia WA 98507-7160 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. IN SR POLICY NUMBER POLICYEFFECTNE POLICY EXPIRATIONF INSURANCE DATE(MWODrffl LIMITS A GENERALLIABILITY 2831366 2/15/2005 2/15/2006 EACHDcCUREENNCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $ 50,000 CLAIMS MADE li-I OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PEP, PRODUCTS-comp/op AGG $ 2,000,000 POLICY X PRO• LOC B AUTOMOBILE LIABILITY CA62658522 2/15/2005 2/15/2006 COMBINED SINGLE LIMIT $ 1,000,000 X ANYAUTO (Eaeraiderd) ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Perperson) $ X HIREDAUTOS BODILYINJURY $ X NON-OWNEDAUTOS (Peraecdent) PROPERTY(PeraccidentDAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC; $ AUTO ONLY: AGG $ C XCESSIUMBRELLA LIABILITY AAU 7 0 5 9 7 8 2/15/2 0 05 2/15/2 0 06 EACH OCCURRENCE $ 1,000,000 OCCUR CLAIMS MADE AGGREGATE $ 1,000,000 $ DEDUCTIBLE $ X RETENTION $10,0 0 0 $ TH- WORKERS COMPENSATION AND WC STATUS O T YLIMITS ERR EMPLOYERS'LIABILITY El-EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECU nVE OFRCERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 1$ j I describe urder SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Date of Display: July 3, 2005. Location: Alderbrook Inn Dock at 7101 E St Rt 106, Union WA. Addl. Insureds: North Forty, North Forty Lodging LLC, Alderbrook Inn, Maureen Woodcock (Property Owner Spectator Area), Jeffrey & Patricia Raikes (Partial Sponsors),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 BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER North Forty WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 22526 SE 64th Place CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO Suite 210 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Issaquah WA 98027 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ®A�NCf ORRDDQCR1LOd/R�RPPO'RATION 1988 o ' ?rk _ Ako�r �oo