HomeMy WebLinkAboutFIR2013-00040 - FIR Permit / Conditions - 12/30/2013 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
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FIRE PROTECTION PERMIT FIR2013-00040
APPLICANT: WOLVERINE WEST, LLC RECEIVED: 12/17/2013
CONTRACTOR: LICENSE: EXP.- ISSUED: 12/30/2013
SITE ADDRESS: 10 E ALDERBROOK DR UNION EXPIRES: 6/30/2014
PARCEL NUMBER: 322335000014
LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58
PROJECT DESCRIPTION: FIREWORKS DISPLAY FOR ALDERBROOK RESORT NEW YEARS EVE 2013
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?:
Dry Chemical?: Pressure Switches:: Smoke Detectors: Duct Detectors:
Zones: Heat Detectors:
Wet Chemical?:
Sprinkler?:
Standpipe?: SQUARE FOOTAGE FEES
Monitoring Company: First Floor: Type Amount Due Amount Paid
Monitoring Phone No.:() - Second Floor: Fireworks Display Permit $250.00 $250.00
Auto Fire Alarm?: Third Floor;:
Total: $250.00 $250.00
FIR2013-00040 Please refer to the following pages for conditions of this permit. Page 1 of 5
CASE NOTES
FIR2013-00040
CONDITIONS FOR
FI R2013-00040
1.) A clear zone of 70 feet per 1 inch of mortar diameter is required. Maximum mortar size that can be discharged from the float/dock area is 4 inch.
X
Per section 5608.4 of the 2012 International Fire code.
Clearance:
Spectators, spectator parking areas, an dwelling, building or structures shall not be located within the display area.
Exception: 2. This provision shall not apply to un-occupied dwellings, buildings and structures with the approval of the building owner and the fire code
offical. It shall be the responsiblity of the display holder to obtain approval from the property owners prior to the fireworks display.
X
Per section 5608.6 of the 2012 International Fire code.
Mortars for firing fireworks shells shall be installed in accordance with NFPA 1123 and shall be positioned so the shells are propelled away from the
spectators and over the fall out area. Under no circumstances shall mortars be angled toward the spectators veiwing area. Prior to Placement, mortars
shall be inspected for defects, such as dents, bent ends, damaged interiors and damaged plugs. Defective mortars shall not be used.
X
Post fireworks display, the firing crew shall conduct an inspection of the fall out area for the purpose of locating unexploded aerial shells or live
components. This inspection shall be conducted before the public access to the site shall be allowed. Where fireworks are displayed at night and it is not
possible to inspect the site thoroughly, the operator or designated asistant shall inspect the entire site at first light. . A report identtifying any shells that
failed to ignite in, or discharge from, a mortar or fail to function over the fallout area or otherwise malfunction, shall be filed with the fire code offical.
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There shall be a minimum of 2 approved water filled pressurized fire extinguishers.
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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.
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3.) Valid Permit Must be on-site.
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FIR2013-00040 Please refer to the following pages for conditions of this permit. Page 2 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.
Signature Date
OWNER - REPRESENTATIVE - CONTRACTOR
Print Name (Circle one to indicate)
FIR2013-00040 Please refer to the following pages for conditions of this permit. Page 3 of 5
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55 N CONCRETE MECHANICAL MANUFACTURED HOME pr
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L Footings !Setbacks Gas Piping Ribbons m
C Interior Date By Interior-Date By Date By X
O Exter" Date By Exterior-Date B Set-up z
o Point Load/Isolated Footings INSULATION Date By
Date _ By Date SLAB INSULATION By FIRE DEPARTMENT M
Foundation Walls Floors Date Ely
Date By bate By DECKS r
FRAMING Wails Date By n
Date By Data By PROPANE TANKS
PLUMBING Vault Date By
Date By OTHER
Groundwork Attic
Date By pate By Type.Date By
D.W.v DRYWALL. type-
Int Brace Wall Date By
Date SY Date By FINAL INSPECTION N
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Date By Date By Date By Ca
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Type of Insp. Fail Date Date Done By Comments c
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AyoN �oU��f MASON COUNTY (360)427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfair ext. 352
y` BUILDING • PLANNING • FIRE MARSHAL (360)482-5269 Elma ext. 352
Mason County Bldg. 111, 426 West Cedar Street
1854 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us
FIR20 1�! -0000g0
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: LI'C'
Mailing Address: _�► .n.3px qqpq5 City: State:LJA Zip: Cf bf39
Phone #: aptp,�-{r�f ,Q Q I `r Email: l
Sponsor Information:
Name:
Address: lL City: n State: Zip: 8 a
Phone #: Email:
Washington State Fireworks License Information (Copy Required):
License Number: Date of Issuance
❑ Pyrotechnic Operator License ❑ Fireworks Stand License
Bond or Certificate of Insurance (Copy of Certificate/Bond Required):
Provider:
Insured:
Certified Holder:
Location of Stand/Display: � !
Site Address:
Directions to Site:
Parcel Number: (twelve digit number) - - 600 I
Legal Property Owner
**Please see reverse side to complete your application**
<�_I,c_,A -3&o- 7,q1-
IACommunity DevelopmentTIRE MARS RALTireworks Permit application.doc
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
Applicants Affidavit
a
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
hCommunity DevelopmentTIRE MARSHAUFireworks Permit application.doc
s 1 a { "stf \z � a t _x 'r"wk�ys n £# f�#� �1 F f'. b ywv 5 £�� (ff �'eY �Yc'r d
s �
v y tffir^} W""Rion State.Porot
Ohke Of The State Fire ly bd
y State Fij etW40 sDense er Disp al ter e
General-Display: Wolverine West, L. L. C.
Post Office Box 9909.5
Seattle,WA 98139W95 Detach this wallet card and tarn'with you for
verification of certification.
Ia,-SSate';Rcpresentative; RodneyF. Hash -
- im isurem 14612
Phone Number: (206)459-0917
I Office Of 1I*State Ftre Marrbal
jGeneral Display: W t,L.L.C.
Date of Issue Expiration Date LicenseNumber � Ueense Nnml7er:
I Type of License:
January 24, 2013 January 31,2014 C-04138 a phone.NumLmr.
I Expiration Date: J 4
1
3000-420-012(R 9/)5) Itift true i Licedsce Signature
Washington State Patrol 15051
Fire Protection Bureau
Office Of The State Fire Marshal
Washington State Fireworks License
Pyrotechnic Operator License
Pyrotechnic Operator: Rodney F. Hash
Licensee Location: Post Office Box 99095 Detach this wallet card and cant'with you for
verification of certification.
Seattle, WA 981390095
Washington State Patrol
Fire Protection Bumau 15051
Phone Number: (206)459-0917 i Office O[The State nth Marshal
i
Pyrotechnic O erator�� .Hash
License Numbe 0
Date of Issue Expiration Date License Number I T e of Licens ~ Operator
January 23, 2013 January 31, 2014 P-04255
Ex iration Dat '";, �,2014
I r ,sae
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3000420-012(R 9/05) I State Fire Mars ture Licensee Signature
i
Certificate of Insurance
2391 Issue Date: 12/6/2013
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/13-0008 2/1/2013 2/1/2014 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/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holder is additional insured as respects the following:
Date(s)of Display: 12/31/2013
Location: 7101 E State Highway 106
Union,WA 98592
Additional Insured: Alderbrook Resort&Spa,Mason County&its employees ATIMA
Rain Date(s): 12/31/2013
Type of Display: Aerial
CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION 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 INSURERITS
AGENTS OR REPRESENTATIVES.
Union,WA 98592
AUTHORIZED REPRESENTATIVE
PART I ®® ro■® APPLICATION DATE OF APPLICATION
FOR PUBLIC FIREWORKS DISPLAY PERMIT 12/11/13
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 ADDRESS LICENSE#
Chad Beebe 11210 Saskatoon Ln SE, Olympia WA 98508 P-04245
NAME OF ASSISTANTS: at least one required)
NAME ADDRESS AGE
Aaron Webb 800 Yauger Way SW E-208, Olympia WA 98502 40
NAME ADDRESS — AGE
EXACT LOCATION OF PROPOSED DISPLAY
LOCATION
Alderbrook Resort & Spa - 7101 E Hwy 106, Union, WA 98592
DATE TIME
12/31/13 9pm
NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED
(11) Multi-Shot Cakes, (276) 2.5" Shells (50) 3" Shells
MANNER&PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority)
In our approved magazines _
SIGNATUIRE 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
Washington state Pstrnl 14611
Fire Protection Burean
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 Parrot
1 Rm Protection Bureau 14 611
Phone Number: (206)459-0917 office Of The state Fire Marshal
i Wholesaler: W F st, L. L.C.
I License Number:
Date of Issue Expiration Date License Number 1 Type of License: V
January 24,2013 January 31, 2014 C-04138 Phone Number:
I Expiration Date: J 4
3000-420-012(R 9/05) Fire i azure —Liccn signature
Washington State Patnol
Fire Protection Bureau
14610
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 wadangton State)PatM
I Fire Protection Bumu 14 610
Phone Number: (206) 459-0917 Office Of state Mn Mar"
l Importer: W st,L.L.C.
I
Date of Issue Expiration Date License Number I License Number: y
Type of License: �.
January 24, 2013 January 31, 2014 C-04138 Phone Number:
i Expiration Date: J h` 4
i
3000420-M(R 9105) 1 tare Fire firs i ature ic�sce Signature
Mason County Department of Community Development 12/18/2013
r601A COU BUILDING•PLANNING•FIRE MARSHAL 8:06:28AM
Mason County Bldg. III, 426 West Cedar Street
PO Box 279, Shelton, WA 98584
Permit status and inspection results can now be checked on the web-www.co.mason.wa.us/permits
trs, Building Dept. inspections requests can be made via the web -www.co.mason.wa.us/community_dev
Receipt #: S1201300000000001266
Date: 12/18/2013
Line Items:
Case No Tran Code Description Revenue Account No Amount Paid
FIR2013-00040 Fireworks Display Permit 001.000000.125.140.321.30.300030.0000.00 250.00
PRIMARY APPLICANT FOR FIR2013-00040: WOLVERINE WEST,LLC
Line Item Total: $250.00
Payments:
Method Payer Bank No Account No/Check No Confirm No How Received Amount Paid
Check WOLVERINE WEST LLC US BANK 5119 In Person 250.00
Payment Total: $250.00
Page 1 of 1 cReceipt.rpt
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