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Home My WebLink AboutFIR2019-00036 - FIR Application - 12/10/2019 coUtiTF MASON COUNTY (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 '" PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR20 -_QDQDCP 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: Alderbrook Resort & Spa Mailing 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: P-04311 Date of Issuance 3/14/19 ^Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: The Partners Group, Ltd. Insured: Wolverine West, LLC Certified Holder: Alderbrook Resort & Spa Location of Stand/Display: Site Address: 7101 E WA-106, 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** ,�� 3� - 50 - oov �� 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. Signed Date 12/10/19 L J�® APPLICATION -- 1 PART I DATE OF APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT 12/10/19 TO: Governing body of city, town, or_county in which display is to be conducted. APPLICANT NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa— 7101 E WA-106, Union WA 98592 360.898.2252 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE Aaron Webb 5030 180th Trail SW, Rochester WA 98579 P-04311 NAME OF ASSISTANTS: at least.one re, uired NAME ADDRESS AGE Herb Harris 2115 9th Ave SW Apt F2, Oly WA 98502 P-04312 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Dock - 7101 E WA-106, Union WA 98592 DATE 12/31/19 TIME midnight NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED Not to exceed [50] 3" shells - [30] 4" shells - [15] cakes MANNER&PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines - ,— -- -------- -- ----- SIGNATU11RE OF APPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) The Partners Group ® Bond or certificate of insurance attached ADDRESS - ❑ Bond or certificate of insurance on file with State Fire Marshal 11225 SE 6th St., Suite 110 Bond or certificate of insurance shall provide minimum coverage of Bellevue, WA 98004 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage rE II PERMIT RMIT# DATE: 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 LIABILITY INSURANCE DAT 1 1/6/2D/YYYY) `...,� /6/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Janet NaU The Partners Group Ltd PNAME:HDNE - - FAx - 11225 SE 6th St., Suite 110 •425-455-5640 (A/C. a Noll:425-455-6727 Bellevue WA 98004 ADORE : jnau@tpgrp.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:T.H.E.Insurance Company 12866 INSURED 15639 INSURER B:Alaska National Ins CO Wolverine West, LLC DBA Wolverine West Fireworks INSURERc_ PO Box 628 INSURER D: Chehalis WA 98532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2053861570 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR r TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER M MWDD LIMITS A GENERAL LIABILITY Y CPP010545603 5/1/2019 511/2020 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea n S 100,000 CLAIMS-MADE I -- 1 OCCUR MED EXP(Any one person) SO PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $10,01D0,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY 7 JECTPRO LOC $ A AUTOMOBILE LIABILITY CPP010645503 5/1/2019 511/2020 COMBINED SINGLE LIMIT acdden 1.000.0D0 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED Ix SCHEDULED AUTOS AUTOS BODILY INJURY(Por accident) S k HIRED AUTOS NON-OWNED PROPERTY DAMAGE : AUTOS _ $ A UMBRELLA LIAR X OCCUR ELP001218203 5/1/2019 5/1/2020 EACH OCCURRENCE $4,0D0,000 X EXCESS LIAR CLAIMS-MADE AGGREGATE $4,000,000 DELI I RETENTION GLONLY s B WORKERS COMPENSATION 19FWU09079 6/25/2019 SQ5I2020 WC STATLL OTH AND EMPLOYERS'LIABILITY Y/N ER USL&H On ly ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If Yes,describe under -- DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $1 000 000 A Auto Excess Liability ELP001218303 511/2019 5/1Q020 Each Occurence 4000000 -Occurrence Apprepete 4:000:000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Certificate holder is included as Additional Insured on General Liability as their interest may appear as respects operations performed by or on behalf of the Named Insured,as required by written contract. Alderbrook Resort&Spa, Mason County&its employees ATIMA are Additional Insured as respects the 7/3/19, 11/29/19, 12/31/19 Aerial Fireworks Displays located at Alderbrook Resort&Spa,7101 E State Highway 106,Union,WA 98592. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Alderbrook Resort&Spa 7101 E State Highway 106 Union WA 98592 AUTHORIZED REPRESENTATIVE Oc 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Policy #CPP010545603 ADDITIONAL INSURED — FIREWORKS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional insured: 1. The fair or exhibition association, sponsoring organization or committee for the fireworks event covered under the policy; 2. The owner or lessee of any premises used by the Named Insured for the covered fireworks events; 3. The public authority municipality granting a permit to the Named Insured to operate the covered fireworks event; and 4. Any independent contractor who operates the fireworks display on behalf of the Named Insured; but only as respects accidents arising out of the negligence of you or your employees while acting in the course and scope of their employment. All other terms and conditions of the policy remain unchanged. CG133F(07/95) **yM6TOper+�P Washington State Patrol Fire Protection Bureau G20120 Office of the State Fire Marshal ` general Display Fireworks License Licensee Data Operational Data Wolverine West, LLC In State Agent: Rodney F. Hash Post Office Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 16, 2019 Date of Expiration:January 31, 2020 at - ` 4 eTwt— 00-11 A -- State Fire Marshal Licen a Signature 3000420411(10118) Washington State Patrol Fire Protection Bureau G20119 Office of the State Fire Marshal Importer Fireworks License f a�xtwa` °fi Licensee Data Operational Data Wolverine West, LLC In State Agent: Rodney F. Hash Post Office Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 16, 2019 Date of Expiration:January 31, 2020 .lft/ -j 00*r/ "WA_1 �� - zo State Fire Marshal Lice ee Signature 3OW-420.041(10118) IF Washington State Patrol Fire Protection Bureau t0069P Office of the State Fire Marshal Pyrotechnic Operator License �W Licensee Data Rodney F. Hash Phone Number: (206) 459-0917 P.O. Box 628 Email Address:rod@wolverinewest.com Chehalis, WA 98532 Date of Issue: January 30, 2019 License Number: P-04255 Date of Expiration: January 31, 2020 State Fire Marshal Licensee Signature 3000-420-043(10/13) Licensee Wall Mount Carr/