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Home My WebLink AboutFIR2014-00040 - FIR Permit / Conditions - 11/25/2014 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line (360)427-7262 r' �' r��, •, Phone: 360 427-9670,ext. 352 Mason County Bldg. III 426 W. Cedar St Shelton, WA 98584 FIRE PROTECTION PERMIT FIR2014-00040 APPLICANT: ALDERBOOK RESORT& SPA RECEIVED: 11/24/2014 CONTRACTOR: WOLVERINE FIREWORKS DISPLAY INC LICENSE. EXP. ISSUED: 11/25/2014 SITE ADDRESS: 10 E ALDERBROOK DR UNION EXPIRES: 5/25/2015 PARCEL NUMBER: 322335000014 LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58 PROJECT DESCRIPTION: FIRE WORKS DISPLAY GENERAL INFORMATION System Information Type of Use: DIS Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 6 Flow Switches: Visual Devices: Door Releases: Hood &Duct?: N Pressure Switches:: Smoke Detectors: Duct Detectors: Dry Chemical?: N Zones: Heat Detectors: Wet Chemical?: N Sprinkler?: N Standpipe?: N SQUARE FOOTAGE FEES Monitoring Company: FirstFloor: Type Amount Due Amount Paid Monitoring Phone No.:() - Second Floor: Auto Fire Alarm?:N Third Floor;: Total: $0.00 FIR2014-00040 Please refer to the following pages for conditions of this permit. Page 1 of 3 CASE NOTES FIR2014-00040 CONDITIONS FOR FIR2014-00040 1.) Valid Permit Must be on-site. X RFH 2.) Owner/Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28. X RFH 3.) 1. No boats to be within the 400' isolation area. This includes boats tied up to the dock. OWNER/BUILDER acknowledges submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below. I declare that I am the owner, owners legal representative, or contractor. I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for review and inspection. This permit/application becomes null &void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. _ n�n�t�ll" �cnna�l Signature Date by Rodney Hash -0-,+,,. �n� n � � �c OWNER - REPRESENTATIVE - CONTRACTOR Print Name ate!201 4. 1 .2 (Circle one to indicate) 10:15:02 -08'00' FIR2014-00040 Please refer to the following pages for conditions of this permit. Page 2 of 3 -n r N CONCRETE MECHANICAL MANUFACTURED HOME Date L Footings t Setbacks Gas Piping By Ribbons CInterior Date By interior-Date By Da1e By O O Exterior Date By Exterior-Date By Sat-up O CD c t Point oad r Isalatad Footings INSULATION Date By BG/SLAB INSULATION Date By Data By FIRE DEPARTMENT m m Foundation Walls Floors Date By O Date By Datz By DECKS � FRAMING walls Date By Qo Date By Data By PROPANE TANKS CAI PLUMBING vault Da1e ' ._ ... D aato By OTHER Groundwork Attic - Type- Date By Date Date By D.W.V DRYWALL type_ Int Brace Wall Date Py m Date By Date By y FINAL PE ON r c m Water Line Fire S spa ration I t �j 1 Date By Date By Date A By ? O 0 Pass or Request Inspect. CD ype Q Fail Date ate Dome By Comments c o k*PX --q5x� I?Aae� 0 IL fQ � d �Q fD N O n O O. S y i j i e I v CD W 0 w MASON COUNTY (360)427-9670 Shelton ext.352 DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfatrext. 352 BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext. 352 Mason C �Tdg. III, 426 West Cedar Street PO 79, S Iton, WA 98584 www.co.mason.wa.us IVED FIR2014 -�_� �M� Y 2 4 20N w tou ty FirewQ 'eEit Application \N 001 o Al E 4 ' .s�� to lications will not be acce ted cs< bli display of fireworks is required. A completed entation and fees shall be submitted for Fire Marshal �►� 1 issued upon satisfactory site inspection by the Fire Marshal. t n ation: e • Iderbrook Resort & Spa ing 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: C-04138 Date of Issuance 2/3/14 ^Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: Professional Program Insurance Brokerage Insured: Wolverine Fireworks Display, Inc. Certified Holder: Adam & Anne Farrens Location of Stand/Display: Site Address: Union WA 98592 Directions to Site: see attached Parcel Number: (twelve digit number) - - Fired on Puget Sound Legal Property Owner n/a **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 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. Digitally signed by Signedwn v Rodney Hash Date 11/20/14 Date:2014.1 1.20 15:36:57-08'00' ��■! PART I wwwa�o.ana,..a APPLICATION DATE OF APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT 11/20/14 TO: Governing body of city,town, or county in which display is to be conducted. APPLICANT NAME ADDRESS ; PHONE Wolverine West Fireworks PO Box 99095 - Seattle, WA 98139 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E Hwy 106, Union, WA 98592 360.898.5529 PYROTECHNIC OPERATOR NAME Z,/' - I S s ADDRESS LICENSE# Chad Beebe-o 0 S 11210 Saskatoon Ln SE, Olympia WA 98508 P-04245 NAME OF ASSISTANTS: at least one . uired NAME ADDRESS AGE Aaron Webb 800 Yauger Way SW E-208, Olympia WA 98502 41 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Resort & Spa - 7101 E Hwy 106, Union, WA 98592 DATE TIME 11/28/14 5:30pm NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED (18) Multi-Shot Cakes, (20) 30mm comets MANNER&PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Local Fire Authority) In our approved magazines _ SIGNATUtZE OF APPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) Professional Program Insurance Brokerage ® Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 371 Bel Marin Keys Blvd. Ste. 220 Bond or certificate of insurance shall provide minimum coverage of Novato, CA 94949 $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. NAME: (Full name of person,firm,or corporation granted permit) RESTRICTIONS: Permit not valid without verification of (Signature of Official granting permit) the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee Certificate of Insurance 5442 Issue Date: 11/6/2014 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF Professional Program Insurance Brokerage INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 371 Be] Marin Keys Blvd., Suite#220 CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT Novato, California 94949 AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED INSURER A: Underwriter's at Lloyd's, London Wolverine Fireworks Display, Inc. INSURER B: 205 W. Seidlers Road Kawkawlin, MI 48631 INSURER C: INSURER D: COVERAGES: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(DD/MM/YY) DATE(DD/MM/YY) A GENERAL LIABILITY PY/14-0013 2/1/2014 2/1/2015 EACH ACCIDENT $5,000,000 CLAIMS MADE MEDICAL EXP(any one person) FIRE LEGAL LIABILITY $50,000 GENERAL AGGREGATE $5,000,000 PRODUCTS-COMP/OPS AGG DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is additional insured as respects the following: Date(s)of Display: 11/28/2014, 12/31/2014 Location: 7101 E State Highway 106 Union,WA 98592 Additional Insured: Alderbrook Resort 8 Spa,Mason County&its employees ATIMA Rain Date(s): 11/28/2014, 12/31/2014 Type of Display: Aerial Fireworks Display CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXIPIRATION DATE THEREOF,THE ISSUING INSURERE WILL ENDEAVOR TO MAIL 10 DAYS Alderbrook Resort&Spa WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 7101 E State Highway 1 O6 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURERJTS 9 Y AGENTS OR REPRESENTATIVES. Union,WA 98592 AUTHORIZED REPRESENTATIVE Alderbrook Resort 0 o� s NN otw Rlp� e e °o;.:• ,.� `� FINE WORKS , ► 1990 d ° Irriagery Date: S,5/2013 lat 4Z35032,7,4 on "1?3`070401° eleV Oft e .. +�► . Washington State Patrol Fire Protection Bureau 15865 Office Of The State Fire Marshal Washington State Fireworks License Importer License Importer: Wolverine West, L. L. C. Post Office Box 99095 Seattle, WA 981390095 Detach this wallet card and carry with you for verification of certification. In-State Representative: Rodney F. Hash Washington State Patrol IIre Protection Bureau 15865 Phone Number: (206)459-0917 Office Of The State Fire Marshal Importer: est,L.L.C. Date of Issue Expiration Date License Number License Number: Type of License: February 3, 2014 January 31, 2015 C-04138 Phone Number: j Ea ira ion te• 15 I 3000-420-012(R 9/05) I State Fire MarsV/ifkature Licensee Signature Washington State Patrol 15864 Fire Protection Bureau Office Of The State Fire Marshal Washington State Fireworks License Wholesaler License Wholesaler: Wolverine West, L. L. C. Post Office Box 99095 Seattle, WA 981390095 Detach this wallet card and carry with you for verification of certification. In-State Representative: Rodney F. Hash Washington state Patrol Fire Protection Bureau 15864 Phone Number: (206)459-0917 Office Of The State Fire Marshal I Wholesaler: *est' L.L.C. Date of Issue Expiration Date License Number I License Number:Type of License: February 3, 2014 January 31, 2015 C-04138 Phone Number:E it tion D t 5 1000-420-012(R 9/05) State Fire v Eicensee Signature Washington State Patrol Fire Protection Bureau 15863 Office Of The State Fire Marshal Washington State Fireworks License General Display License General Display: Wolverine West, L. L. C. Post Office Box 99095 Seattle, WA 981390095 Detach this wallet card and carry with you for verification of certification. In-State Representative: Rodney F. Hash Washington State Patrol Fire Protection Bureau 15863 Phone Number: (206)459-0917 I Office Of The State Fire Marshal I General Disnlav: W, West,L. L.C. Date of Issue Expiration Date License Number I I License Number: r y Tvae of License: February 3, 2014 January 31,2015 C-04138 Phone Number: Expiration Date: 15 I i t reKu � I r I 3000 420 012(R 9/05) I State Fire mars ature Licensee Signature Washington State Patrol 15856 Fire Protection Bureau Office Of The State Fire Marshal Washington State Fireworks License Pyrotechnic Operator License Pyrotechnic Operator: Rodney F. Hash Detach this wallet card and carry with you for Licensee Location: Post Office Box 99095 verification of certification. Seattle, WA 981390095 - Washington State Patrol Phone Number: (206)459-0917 I Fire Protection Bureau 15856 Office Of The State Fire Marshal I I Pyrotechnic Hash IN Date of Issue Expiration Date License Number i Li en f I c Operator January 31, 2014 January 31, 2015 P-04255 Expirst1 a 1 2015 I I3000-420-012(R 9/05) State Fire dmbpllfure Licensee Signature