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HomeMy WebLinkAboutFIR2018-00031 - FIR Application - 6/5/2018 1 �oU MASON COUNTY (360)427-9670 Shelton ext.352 �N DEPA TMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfairext. 352 BOIL ING•PLANNING. FIRE MARSHAL (360)482-5269 Elma ext. 352 -3 M 5t County Bldg. III, 426 West Cedar Street 1854 & O x 79, Shelton, WA 98584 www.co.mason.wa.us FIR20�- OOO�j Mason County Fireworks Permit Application " Incomplete applications will not be accepted k , - 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: Wolverine West Fireworks Mailing Address: PO Box 628 City: Centralia State: WA Zip: 98532 Phone#: 360.790.3409 Email: aaron@wolverinewest.com Sponsor Information: Name: Alderbrook Resort & Spa Address: 10 E. Alderbrook Drive City: Union State: WA Zip:98592 Phone #: 360.898.2252 Email:jake.geist@alderbrookresort.com Washington State Fireworks License Information (Copy Required): General Display License License Number: C-04138 Date of Issuance 1/30/18 Xpyrotechnic Operator License o Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: The Partners Group Ltd u Insured: Wolverine West LLC Certified Holder: Alderbrook Resort 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" t 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 es--orzli Qrks shall be maintaine�a ro n R. Digitally sign_edbyAaron ebb DN:cn�on R.Webb,o Wolverine Signed West,LLC,ou=Display Man er, Date 6/5/18 c=US PART I APPLICATION DATE OF APPLICATION FOR PUBLIC FIREWORKS DISPLAY PERMIT 6/5/18 TO: Governing body of city,town, or coun in which display is to be conducted. APPLICANT _ NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 360.790.3409 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 10 E Alderbrook Dr Union, WA 98592 360.898.5529 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Webb 5030 180th Trail Rochester WA 98579 P-04311 NAME OF ASSISTANTS: at least one re uired NAME ADDRESS AGE Nicholas Wolfe-Webb _ 5030 180th Trail Rochester WA 98579 21 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Resort & Spa - 10 E. Alderbrook Dr, Union, WA 98592 DATE TIME 7/3/18 10:15pm NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED Not to exceed:(12) Multi-Shot Cakes, (250) 3" Shells, (200) 4" Shells, (87) 5" Shells, (36) 6" Shells (2) 8" shells MANNER&PLACE OF STORAGE PRIOR TO DISPLAY(Subject to approval of Local Fire Authority) In our approved magazines „ _ wso'y'" y Aarw.ee. auy— SIGNAT E OF APPLICANT "oMw P6ymw`1. Webb 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 QQ PERMIT PERMIT# I 20(U OOa3 DATE: "0 �'► In accordance with the provisions of RCW 70.77 pplicable local ordinances, this permit is granted to conduct a fireworks display as per the above application. r J, NAME: Co (Full nam of person,firm,or co oration granted permit) I 2.O l E5 10: 15 M 17 %,Y1 Permit not valid without verification of (Si ature of facial granting permit) the appropriate State Fireworks License ! aA (Title) LICENSE NUMBER?O L25 —o 4 2 1 6 (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee i t _ CERTIFICATE OF LIABILITY INSURANCE DATE 6/1/20�8 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 NAME: The Partners Group Ltd PHONE -"— FAX 11225 SE 6th St., Suite 110 •425-455-5640 uuc,No►:425�55-6727___ Bellevue WA 98004 notiliess: rjessenOtpgrp.com INSURERS AFFORDING COVERAGE NAIC e INSURER A:T.H.E.Insurance Company 12866 INSURED 15539 INSURER B Wolverine West, LLC Wolverine West Fireworks INSURER C: PO BOX 628 INSURERD: Chehalis WA 98532 INSURER E: I rINSURER F: COVERAGES CERTIFICATE NUMBER: 1748877146 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 TYPE OF INSURANCE AD L UBR POLICY NUMBER MM/DDPOLICYIYYYY MM/DD EFF POLICY EXP LIMITS LTR A GENERAL LIABILITY Y CPP010545602 5/12018 5/12019 EACH OCCURRENCEDAMAGE To X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $100,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE S Unlimited GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO- LOC III -- — AUTOMOBILE LIABILITY COMBINED SIN L LIMI Ea accident ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED SCHEDULEDAUTO AUTOS BODILY INJURY(Per accident) $ H REDSAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per a ent $ A UMBRELLA LIAB X OCCUR Y ELP001218202 5/12018 5/1/2019 EACH OCCURRENCE S 4,0D0,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTIONS $ WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDI N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The following are Additional Insured on General Liability as their interest may appear as respects to 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 7/3/18,11/23/18,12/31/18 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 AUTHORIZED REPRESENTATIVE Union WA 98592 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 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) Alderbrook 2017 800ft forshells Aderbrook ResorlS.. --E Hai,e'-Avr• —� -- 'J�FB EJUf7 AVC' Cn � — —F n I M ( f r i s ® E GlYrrip. El Wu— ,� • H 0 ✓ s :. f Ade'r rook Resort & Spa Goo8le-earth N _'Q7F,i3pn7'F • 4 ". x :�}',ie_ ',, 1 00 ft , �►'�T"'�'+ Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal General Display Fireworks License 18-1190 Licensee Data Operational Data Wolverine West, L.L.C. In State Agent: Rodney F. Hash P.O. Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 30, 2018 Date of Expiration:January 31, 2019 1021,f /. . " 24. t State Fire Marshal Licensee Signature Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Importer Fireworks License 18-1163 Licensee Data Operational Data Wolverine West, L.L.C. In State Agent: Rodney F. Hash P.O. Box 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: rod@wolverinewest.com License Number: C-04138 Date of Issue:January 30, 2018 Date of Expiration:January 31, 2019 State Fire Marshal Licensee Signature 'g Washington State Patrol Fire Protection Bureau Office of the State Fire Marshal Pyrotechnic Operator License 18-1343 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, 2018 License Number: P-04255 Date of Expiration: January 31, 2019 ZA(9 0 0 State Fire Marshal icensee Signature i Licensee Wall Mount Card .RT APPLICATION GATE OF APPLICATION LUM.' FOR PUBLIC FIREWORKS DISPLAY PERMIT 6/5/18 TO: Governing bodyof city,town, or countyin which display is to be conducted. °-APRLICA.NT _ y f NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628 - Chehalis, WA 98532 360.790.3409 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 10 E Alderbrook Dr, Union, WA 98592 360.898.5529 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Webb 5030 180th Trail Rochester WA 98579 P-04311 `NAME OF ASSISTANTS: at:least-one�re uired NAME ADDRESS AGE Nicholas Wolfe-Webb 5030 180th Trail Rochester WA 98579 21 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Alderbrook Resort & Spa - 10 E. Alderbrook Dr, Union, WA 98592 DATE TIME 7/3/18 10:15pm NUMBER AND KINDS QF FIREWORKS TO BE,DISPLAYED T. Not to exceed:(12) Multi-Shot Cakes, (250) 3" Shells, (200) 4" Shells, (87) 5" Shells, (36) 6" Shells (2) 8" shells MANNER'& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authod = In our approved magazines _ wero�°° -°p eb ON.wAron N.Webb, SIGNATORE OF APPLICANT Webb °"."�.. ` FINANCIAL'.RESPONSMIILR Y 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# j C., ��18 DATE: Lo " 1 3 �7- o ( 8 In accordance with the provisions of RCW 70.77pplicable local ordinances, this permit is granted to conduct a fireworks display as per the above application. NAME: _HRCo (Full nam of person,firm,or co oration granted permit) I (Jl 2 lt6 10, L5 rYJ C.c n F&L Permit not valid without verification of (Si ature of fficial granting permit) the appropriate State Fireworks License 0 (Title) mot! LICENSE NUMBER?' — 0 j42E; 1 � r o 4 l2 16 (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee I