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HomeMy WebLinkAboutFIR2014-00015 - FIR Permit / Conditions - 6/11/2014 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 279 Phone: (360)427-9670, ext. 352 Shelton, WA 98584 1� FIRE PROTECTION PERMIT FIR2014-00015 APPLICANT: WOLVERINE WEST, LLC RECEIVED: 6/11/2014 CONTRACTOR: LICENSE: EXP: ISSUED: SITE ADDRESS: 10 E ALDERBROOK DR UNION EXPIRES: PARCEL NUMBER: 322335000014 LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58 PROJECT DESCRIPTION: FIREWORKS DISPLAY SET FOR 7/3/2014 GENERAL INFORMATIO N System Information Type of Use: DIS Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 6 Hood& Duct t: 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: First Floor: Type Amount Due Amount Paid Monitoring Phone No.:() - Second Floor: Fireworks Display Permit $250.00 $0.00 Auto Fire Alarm?: Third Floor;: p y Total: $250.00 $0.00 I FIR2014-00015 Please refer to the following pages for conditions of this permit. Page 1 of 5 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. Digitally signed by 6/25/14 Signature Radney Hdb!T-- Date Date:2014.06.25 Rodney F. Hash 14:56:19-07'00' OWNER - REPRESENTATIVE - CONTRACTOR Print Name (Circle one to indicate) FIR2014-00015 Please refer to the following pages for conditions of this permit Page 3 of 5 -n 56 N CONCRETE MECHANICAL MANUFACTURED HOME p p Date By < L Footings /Setbacks Gas Piping Ribbons rn OIntenot Date By Interior-Date By Date By X OC Extent Date By Exterior-Date By Set-up m INSULATION Point Load/isolated Footings Date By BG I SLAB INSULATION m Date By Data By FIRE DEPARTMENT M Foundation Wails Floors Date By --I Date By Date By DECKS r FRAMING Walls Date By n Date Data By PROPANE TANKS PLUMBING vault Date By Date ay OTHER Groundwork Attic Date By Date By Type- Date By D.W.v DRYWALL Type Int.Brace Wall Date By Date BY Date By N FINAL INSPECTION No Water Line Fire Seperation j Date By Date By Date By o Pass or Request Inspect. c Type of Insp. Fail Date Date Done By Comments v, 0 p no- ,5 S 7- 0 n O 7 O. O 3 N O N (D M N (fl (D A O Cl Alderbrook Resort July3rd .Jy a� Fireworks cup 14 Op Mi 10 VP .0 mow" �D t ,Q - , F-� » . - FARE WORKS r � ," Imagery Qate: 5/, j/61.3 1at 47.351446 Ion '-123.0725260 elev 13 ft eye alt 31 CHANGES SUBMIT PRIOR TO PER ORMRNG WORK L f `' h IMASON COUNT" FIRE RS)AL. 3 /� [7 DATE�� 1Z� BSA SUBJECT TO FIELD iNSPECTlt _'_ S MUST B� THESE PI-ANSITS ALL APPLICABL CODES Q4ALL APPLY. ESRCP z.S TuL jj13 ^,AND/OR OMISSIONS ON PLANS ARE SOLE Rr O v 1 rr11L. TION SPONSIBILITY OF OWNER/CONTRACTOR.O'= ^ FOR Ini J TIONS REQUIRED FROM FIELD "4SPECT1 �- �.t 19E AT OWNERICONTRACTOR'S EX€EHS_, Ts,I:z :.q'. PROVAL OOES N,01 RRAVT TO -,N`.' ^rR f RIGHT TO VIOI,t:k At Y CtTY O?: STr.aE wis cm.s� APPLICATION DATE OF APPLICATION t�[__APPLICANT T I i I i - uyr FOR PUBLIC FIREWORKS DISPLAY PERMIT 6/10/14 TO: Governingbodyof city, town, or countyin which display is to be conducted. NAME ADDRESS PHONEf Wolverine West Fireworks PO Box 99095 - Seattle, WA 98139 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 7101 E Hvvy 106, Union, WA 98592 360.898.5529 YROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Webb 800 Yauger Way SW E-208, Olympia WA 98502 P-04311 NAME OF ASSISTANTS: at least one required) NAME ADDRESS AGE Herb Harris 210 'Y' St SW, Tumwater, WA 98501 P-04312 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Resort & Spa - 7101 E Hwy 106, Union, WA 98592 DATE TIME 7/3/14 10:15pm NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED (4) Multi-Shot Cakes, (275) 3" Shells, (200) 4" Shells, (87) 5" Shells, (36) 6" Shells I MANNER 8 PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Local Fire Authority) In our approved magazines &UM V_�, SIGNATUlIZE OF APPLICANT FINANCIAL RESPONSIBIUTY 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 3061 Issue Date: 3/28/2014 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF Professional Program Insurance Brokerage INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 371 Bel 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/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is additional insured as respects the following: Date(s)of Display: 7/3/2014 Location: 7101 E State Highway 106 Union,WA 98592 Additional Insured: Alderbrook Resort&Spa,Mason County&its employees ATIMA Rain Date(s): 7/3/2014 Type of Display: Aerial 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 106 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURERITS 9 Y AGENTS OR REPRESENTATIVES. Union, WA 98592 .f AUTHORIZED REPRESENTATIVE Washington State Patrol 15863 Fire Protection Bureau Office Of The State Fire Marshal Washington State Fireworks License General Display License General Disvlav: 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 I wasbtngton state Parrot ' Fire Protection Bureau 15863 Phone Number: (206)459-0917 Office Of Ile State Fire Marshal i General Dismay: W. West,L. L.C. Date of Issue Expiration Date License Number License Number:I Type of License: y February 3, 2014 January 31, 2015 C-04138 Phone Number: Expiration Date: 15 I , 3000-420-012(R 9/05) State Fue Aars Licensee Signature i 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 Fire Protection Bureau 15856 Phone Number: (206)459-0917 Office Of The state Fire Marshal I Pyrotechnic O erat .Hash Date of Issue Expiration Date License Number i Li nse Num a n T e of Li c Operator January 31, 2014 January 31,2015 P-04255 i E: iration Da L'�r {1,2015 I Washington State Patrol 15865 Fire Protection Bureau 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 I Fire Protection Bureau 15865 Phone Number: (206)459-0917 j Office Of The State Fire Marshal j Importer: est,L.L.C. License Number: Date of Issue Expiration Date License Number I Tyne of License: `f February 3,2014 January 31, 2015 C-04138 j Phone Number: Ez lra ion Date: 15 I I 3000-420-0 l2(R 9ro5) I state Fire MarsbVfawre 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 certificration. In-State Representative: Rodney F. Hash Washington State Pam Fire Protection Bureau 15864 Phone Number: (206)459-0917 Office Of The state Fire Marshal I Wholesaler: ° est,L.L.C. License Number: Date of Issue Expiration Date License Number TyDe of License: February 3, 2014 January'31, 2015 C-04138 Phone Number: Expiration Date: 15 r ,; FIRE' ��SON coU�rt MASON COUNTY MARSHAL (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 1854 PO ox 279, Shelton, WA 98584 www.co.mason.wa.us JUN 1 12014 FIR20_1�_- Q101�I 426 W. CEDAR ST 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: OC�L1La lylt;!­ (d Q S+ frI ee ujo I Mailing Address: P.0.5nK1 16Cf5 City:bpi D State:l,� Zip: gg13`1- Phone#: 2 p(D, Ll 5e1 .Oq 1-1 -Email: Sponsor Information: Name: ryQ - Address: I C) G- c. City: l)n l0 n State: zip:,- Phone#: 'Pig q Email: Washington State Fireworks License Information (Copy Required): License Number: _?-0431 1 Date of Issuance ><Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insuraance (Copy of Certificate/Bond Required): Provider:?r-6CK_G6lori&L Insured: Certified Holder: -A V Psi n!_ 112,!✓WQC I,�7 S Location of Stand/Display: Site Address: e IJ If=. 0I'1lOt/1 C1�C1 a Directions to Site: Parcel Number: (twelve digit number) . _ - - I0I Legal Property Owner noe 0r- **Please see reverse side to complete your application** L\Community DevelopmentTIRE MARSHALTireworks Permit application.doc