HomeMy WebLinkAboutFIR2010-00013 - FIR Permit / Conditions - 6/9/2010 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line (360)427-7262
Mason County Bldg.3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670, ext. 352
Shelton, WA 98584
FIRE PROTECTION PERMIT FIR2O1O-00013
APPLICANT: ORION PYROTECHNICS RECEIVED: 5/19/2010
CONTRACTOR: LICENSE: EXP: ISSUED: 6/9/2010
SITE ADDRESS: 7101 E STATE ROUTE 106 COTTAGE 10 UNION EXPIRES: 12/9/2010
PARCEL NUMBER: 322335100010
LEGAL DESCRIPTION: ALDERBROOK COUNTRY CLUB TR 10
PROJECT DESCRIPTION: FIREWORKS DISPLAY
GENERAL INFORMATION System Information
Type of Use: DIS Sprinkler Heads: Audible Switches: Pull Stations:
Fire District: 6
Hood & Duct?: N Flow Switches: Visual Devices: Door Releases:
Dry Chemical?: N Pressure Switches:: Smoke Detectors: Duct Detectors:
Zones: Heat Detectors:
Wet Chemical?: N
Sprinkler?: N
Standpipe?: N SQUARE FOOTAGE FEES
Monitoring Company: First Floor: Type Amount Due Amount Paid
Monitoring Phone No.:() - Second Floor:
Auto Fire Alarm?:N Third Floor;: Fireworks Display Permit $250.00 $250.00
Total: $250.00 $250.00
FI R2010-00013 Please refer to the following pages for conditions of this permit 1 of 3
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CONDITIONS FOR
FIR2010-00013
1.) The display must meet all or me requirements of the zouti International Fire Code the NFPA standards and Washington State Fire Marshal requirements.
The display is.subject to inspection by the Mason County Fire Marshal prior to discharge.
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2-) Valt erm ust be on-site. r 6
3.) Owner I Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28. - -
This permit becomes null and vold If work or construction authorized is not commenced within 160 days, or If construction or work la suspended(or a period of 150 days at any
time after work is commenced. Evidence of continuation of work is a progress Inspection within(he 180 day period. Final inspection must be approved before building can be
oocupied.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 inspectlon-
OWNER OR AGENT: �-�� DATE: ��' I`i'i s
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FIR2010-00013 Please refer to the following pages for conditions of this permit 2 of 3
N CONCRETE MECHANICAL MANUFACTURED HOME X
O Date By Q
Footings !Setbacks Gas Piping Ribbons , Z
CInterior Date By Interior-Date By Date By
Exterior Date
C? By Exterior-Date By Set-up X
W Point Load!Isolated Footings INSULATION Date By I
Date BY
BG!SLAB INSULATION
Data By FIRE DEPARTMENT n
Foundation Walla Floors Date By Z
Date By Data By DECKS a
FRAMING Walls Date By N
Date By Data By PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attic
Date By Date By Type:
Date By
D.w.v DRYWALL Type:
InL Brace wall Date By
0 Date BY pate By FINAL INSPECTION N
m Water Line Fire Seperation O
99 Date By Date By Date By O
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Pass or Request Inspect. CD
Type of Insp. Fail Date Date Do By Comments
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Mason C `unty
Fireworks Permit Application
PO BOX 186
Permit# FIR
�- 426 W Cedar St
Shelton WA 98584 Receipt # .S -oZ oo- hgoZ
(366) 427-9670 ext 273
CK # �38Ys'
Date Received 3 /a
APermit for the Retail Sales or Public display of forks is required. A completed
application with required documentation an 4eeha
ll be submitted for Fire Marshal
review. A permit will be issued upon satisfacsite inspection by the Fire Marshal.
Applicant ,! formation.
Name: 1 -
--Mailing Address: ,- — - - - -
City: s �- 'f��I/f State: U) A Zip: ^�%«
Contact Number 6 )
Sponsor Information
Name: flti> ,2�i�a 4� Ian l r
Mailing Address: -7101 ov
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City: State: r.� f} Zip:
Contact Number
Washington State Fireworks License Information (Copy Required)
License No.: F-Q43111 Date of Issue: JAN 2d1V
�f��Cly 1dtf�,Q
Pyrotechnic Operator License ❑ Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: L'b1. 72 6IiUc O G/FtG%/L_S
Insured: ON , —:nf L N 1
Certified Holder:
Location of stand/display
Address: U
,
Directions to Site*.'
Parcel Number: _ -�J - Dm
Legal Description: c
Legal Property Owner:
* * Please see the Teverse side to complete your application
®® APPLICATION
PART 1 "'"" nA`�,..0. Ma 15t ,2010
FOR PUBLIC FIREWORKS DISPLAY PERMIT y
TO: Governing body of ci town, or county In which display is to be conducted.
non Pyrotecnics askatoon Ln SE,Olympia,WA 98513 1-5055
RE80 C.
er rook Spa and Resort 7101 WA-106,Union Wa 98592 360-898-5529
Aa on Webb 712 36t Ave Olympia WA '36o 3yo9 -04311
.:
INAIMU
Chancey Wilkins 13805 College st#65 Lacey WA 30
CT
IMOM-1 06,Union Wa 98592
my 5th 2010 aprox 10pm
AN # YEQ .
.UlY18I�R OFFI EIAt � BE _ ...
.(240)2.5"Aerial Shells
(288)3"Aerial Shells
(144.)5"Aerial Shells
Ired electricaly
aril 4 ti PRIOII to aR' LQaf K>>re Aut#ii�
$I NA' _ — NT Chad E.Beebe
2010,05.14 15:07:11-07'00'
*ESIPON$
&QLIDINQ OR lN§WBAt&&gQMPANY (Mark One)
Combined Specialties,Inc x❑ Bond or certificate of insurance attached
❑ Bond or certificate of insurance on fife with State Fire Marshal
rNavato,
arin Drive,Suite 5 Bond or certificate of insurance shall provide mininTurn coverage of
alifornia 94945 respectively,and$25,OQ0 bodilyinjury liability fgoe each person and event,
r
lI PERMIT
RMIT# DATE:
accordance with the provisions of RCW 70.77 and applicable local ordinances, this pQL[pif is granted to conduct a
firework
NAME:
RESTRICTIONS:
Permit not valid without verification of (Signature of Official arantina nermitl
the appropriate State Fireworks License
itie)
LICENSE NUMBER:
(Instructions on reverse side)
3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee
Alderbrook Fireworks Display E
July 5th, 2010 (* NE>
Traffic More... Map Satellite Earth
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106
700' Diameter
Secured Permiter
Barge Location
16 AU'
106
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Washing on Hotel-wwv Washington Hyatt com-10 Hyatt Hotels in Washington Best Rates online Guaranteed Sponsored Link
Done 0 Intemet Double-click to change security sett s
Certificate of Insurance
542634 Issue Date:05/17/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Debbie Merlino CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE
Combined Specialties International,Inc. DOES NOT AMEND,EXTEND OR LATER THE COVERAGE AFFORDED BY THE
205 San Marin Drive,Suite 5 POLICIES BELOW.
Novato California 94945 INSURERS AFFORDING COVERAGE
INSURER A:Underwriters,Lloyds of London
INSURED INSURER B:
Pyrotecture,LLC INSURER C:
DBA:Orion Pyrotechnics
12110 Saskatoon Lane SE INSURER D:
Olympia Washington 98513
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 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 AN"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 INSURERS SHOOTER(S)ASSISTANT(S)OR
ANY OTHER PERSON(S)INCLUDING ANY VOLUTEER(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 INSUREDS
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 POLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS
A GENERAL LIABILITY 1269542756/010 April 15,2010 April 15,2011 EACH ACCIDENT $1,000,000
CLAIMS MADE MEDICAL EXP $5,000
(any one person)
FIRE LEGAL LIABILITY $50,000
GENERAL AGGREGATE $2,000,000
PRODUCTS-COMP/OPS AGG $1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY $
ANY OWNED AUTO (Per person)
SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per person)
EXCESS LIABILITY EACH ACCIDENT $
FOLLOWING FORM AGGREGATE $
WORKERS COMPENSATION WC STATU- OTHER
AND TORY LIMITS
EMPLOYERS'LIABILITY $
E.L.EACH ACCIDENT $
E.L.DISEASE-EA EMPLOYER $
E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Alderbrook Spa&Resort,officers,agents&employees as their interest may appear are Additional Insured as respects the July 5,2010(RD:TBD)Fireworks Display at
Alderbrook Spa&Resort,Union,WA
CERTIFICATE HOLDER CANCELLATION
Alderbrook Spa&Resort SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
7101 WA-106 THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
Union,WA 98592 CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO
OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,IT'S AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE