HomeMy WebLinkAboutFIR2011-00053 - FIR Permit / Conditions - 1/10/2012 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262
Phone: (360)427-9670, ext. 352
Mason County Bldg. 3 426 W. Cedar P.O. Box 186
Shelton, WA 98584
0014 FIRE PROTECTION PERMIT FIR2011-00053
APPLICANT: ALDERBROOK RESORT RECEIVED: 12/29/2011
CONTRACTOR: LICENSE: EXP: ISSUED: 1/10/2012
SITE ADDRESS: 10 E ALDERBROOK DR UNION EXPIRES: 7/10/2012
PARCEL NUMBER: 322335000014
LEGAL DESCRIPTION: SUNNY BEACH PCL 1 OF BLA#04-58
PROJECT DESCRIPTION: FIREWORKS DISPLAY FOR SATURDAY- MIDNIGHT
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
Wet Chemical?: N Zones: Heat Detectors:
Sprinkler?: N
Standpipe?: N 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?:N Third Floor;: P y
Total: $250.00 $250.00
FIR2011-00053 Please refer to the following pages for conditions of this permit. Page 1 of 3
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CASE NOTES
FIR2011-00053
CONDITIONS FOR
FIR2011-00053
1.) The access to the site must be in full compliance with ordinance 31-04 title 14 chapter 14.17 of the Mason County Code for fire apparatus access roads.
X
Storage and use of fire works must be in full compliance with RCW70.77, WAC 212-17, NFPA 1123-06, NFPA 1124-06, NFPA 160-06 and chpater 33 of
the 2009 International Fire code.
X
Fire extinguishers must be provided on site per Chapter 9 of the 2009 International fire code and NFPA 10.
X
For 1 inch of diameter of shell size a 70 foot set back is required, 6 inch shells are the larges stated on the application, a minimum 420 foot is required to
all boats, docks, floats of structures of any kind.
X
Per the application, there will be no on site storage of fireworks.
X
An after action report is required to be submitted to the fire Marshals office, because the display occurs at night the following morning the fireworks display
companyt is required to inspect the fall out area within 420 feet to make sure that are no unexploded shells.
X
2.) Valid Permit Must be on-site.
X
3.) 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
This permit becomes null and void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended for a period of 180 days at any time
after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied.
Proof of continuation of work is by means of a progress inspection.The owner or the agent on the owners behalf, represents that the information provided is accurate and grants
employees of Mason County access to the above described property and structure for review and inspection.
OWNER OR AGENT: DATE:
FIR2011-00053 Please refer to the following pages for conditions of this permit. Page 2 of 3
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56 CONCRETE MECHANICAL MANUFACTURED HOME
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Date By Data gy PROPANE TANKS
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Mason County
Fireworks Permit Application P
PO BOX 186
6 W Cedar St Perm
it# FIR r 5
Shelton WA 98584
(360) 427-9670 ext 273 Receipt # ?e -6ZZ2-6
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Date Received
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: �Z
Mailing Address:
City: P�A State. VA Zip:
Contact Number (3�j) I
Sponsor Information
Name: T - -�-
Mailing Address.
City: UraotJ State: c w Zip: 235 g Z-
Contact Number (gyp ) �3ci g S 2cl
Washington State Fireworks License Information (copy Required)
License No.: Date of
Issue: �i 1
Pyrotechnic Operator License ❑ Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider:
Insured: +'�44 7jeCgUa r- --A
Certified Holder:Loca
tion of stand/display
s:
to Site.
Parcel Number: _ q0 _
Legal Description:
Legal Property Owner:
* * Please see the reverse side to complete your application
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The foHowing pertinent information MUST be provided on the site diagram 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 g Parking
• Combustibles • Public Roads and Right of Ways
• Fire Lanes Private Roads and s Right of Ways
Y
• Trees /Brush
Landmarks
• Utilities and Gas • Mortar separation distance
• Desi ated 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.
Signed Date �)
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date:
OR ION-
' PYROTECHNICS
k7lu �1.�1't tlu &—lit
General Notes
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Dock to •' closed during
display.
All devices to be shot
w Cn,ne.i6.>m..M,r,
electronically.
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9 • aerial
finale shot from floating platform
moored to dock.
' '�N r.i o•'TGR
p 7V7M�ylne� p per,. � Setback required =420'
Setback Provided=500'
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Certificate of Insurance
107094 Issue Date: 12/28/2011
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF
s Deborah Merlino INFORMATION ONLY AND CONFERS NO RIGHTS UPON
THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT
Combined Specialties International, Inc. AMEND,EXTEND OR LATER THE COVERAGE AFFORDED
205 San Marin Drive, Suite 5 BY THE POLICIES BELOW.
Novato, California 94945
INSURERS AFFORDING COVERAGE
INSURED
Pyrotecture, LLC INSURER A: Underwriters, Lloyd's London
DBA: Orion Pyrotechnics INSURER B:
11210 Saskatoon Lane SE INSURER C:
Olympia, WA 98513
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 MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INCLUDING,BUT NOT LIMITED TO THOSE FOLLOWING:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,ADDITIONAL CONDITIONS AND EXCLUSIONS:1)THE -
INSURANCE EVIDENCED BY THIS CERTIFICATE IS LIABILITY INSURANCE ONLY,IT IS NOT A BOND OR ANY FORM OF SURETY AGAINST WHICH SOMEONE OTHER THAN'INSURED'MAY ASSERT A CLAIM OR BRING ANY ACTION.
SUBJECT TO POLICY TERMS,CONDITIONS,DEFINITIONS AND EXCLUSIONS THE INSURANCE ONLY INDEMNIFIES AN INSURED AGAINST CERTAIN LEGAL LIABILITY.2)THE INSURANCE DOES NOT COVER CLAIMS FOR BODILY
INJURY OR PROPERTY DAMAGE OF THE NAMED INSURED'S SHOOTER(S)ASSISTANT(S)OR ANY OTHER PERSON(S)INCLUDING ANY VOLUNTEER(S)PARTICIPATING IN ANY WAY IN ANY DISPLAY OR SPECIAL EFFECT
PERFORMED OR EXECUTED BY THE NAMED INSURED.3)COVERAGE DOES NOT APPLY TO CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE ARISING OUT OF THE INSURED'S FAILURE TO FOLLOW NFPA OR OTHER
APPLICABLE REQUIREMENTS,LAWS OR RECOMMENDATIONS,INCLUDING THOSE RELATING TO POST DISPLAY OR SPECIAL EFFECT SEARCHES OR CLEAN UP.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(DD/MM/YY) DATE(DD/MM/YY)
A GENERAL LIABILITY CSI-852908-11 5/15/2011 5/15/2012 EACH ACCIDENT $1,000,000
CLAIMS MADE
MEDICAL EXP(any one person) $5,000
FIRE LEGAL LIABILITY $50,000
GENERAL AGGREGATE $2,000,000
PRODUCTS-COMP/OPSAGG $1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Each accident)
ANY OWNED AUTO
SCHEDULED AUTOS BODILY INJURY(Per Person)
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY(Per Accident)
PROPERTY DAMAGE
(Per person)
EXCESS LIABILITY EACH ACCIDENT
FOLLOWING FORM
AGGREGATE
WORKERS COMPENSATION WC STATUTORY OTHER LIMITS
AND
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT
E.L.DISEASE-EA EMPOYER
E.L.DISEASE-POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Alderbrook Spa and Resort, officers, agents & employees as their interest may appear are Additional Insured as respects the
December 31, 2011 (RD: TBD) Fireworks Display at Alderbrook Spa and Resort, Union, WA
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE
ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
Alderbrook Spa and Resort THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
7101 WA-106
Union, WA 98592
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