HomeMy WebLinkAboutFIR2010-00033 - FIR Application - 11/12/2010 Mason r 'unty
t Fireworks Permit Application
lip PO BOX 186
426 W Cedar St Permit# FIR 2010 - eX?Q�j
Shelton WA 98584
(366) 427-9670 ext 273 Receipt #
CK # 3'q A 3
3 --0 4!5)d/ Date Received I I- 1 a,-aO 10
A Permit for the Retail Sales or Public display o fir orks is required. A completed
application with required documentation a hail be submitted for Fire Marshal
review. A permit will be issued upon satisfa site inspection by the Fire Marshal.
Applicant Information,
Name: W10A)
--Mailing Address.- _ - -- -
City: L State: Zip:
Contact Number &a 7�j�c5Z'��'
Sponsor Information
Name: AtD6-e_� j� 4?
Mailing Address: -1 101 w°�-I pp _
City: :v N tiq j f State: aj,+ Zip: 59 Z
Contact Number ( gip)Mb- 24--
Washington State Fireworks License Information (Copy Required)
License No.: P-091I Date of
IA9434 WW:6 � Issue: JAiv 4AO
Pyrotechnic Operator License �i ❑ -Fireworks Stand License
Bond or Certificate of Insurance
(Copy of certificate/Bond Required)
Provider: c2 0122,6 VtI ,- f G -- 7 L
Insured: 04J-;I/ ' " %C L fo 1
Certified Holder: }
Location of stand/display
Address:
Directions to Site:
Parcel Number: - -
Legal Description:
Legal Property Owner.
* * Please see the reverse side to complete your application
APPLICATION
wsiw�IrG10R S*Ax vxtnx - 9ft US'PYYLIC,HIIVIV
PART I '.,, FOR PUBLIC FIREWORKS DISPLAY PERMIT Nov. 1 o,zol o
TO: Governing body of city,town,or county in which display is to be conducted.
CANT
INS'Pyrotecnics M askatoon Ln SE,Olympia,WA 98513 1-5055
NrdUK ��,.� --
erb rook Spa and Resort 7101 WA-106,Union Wa 98592 360-898-5529
PYROTECHNIC OPERATOR
R3.
aron Webb :��] 712 36th Ave Olympia WA P-04311
— _ON _._..
at _ _t ortie r, _trired)
hancey Wilkins 3805 College st#65 Lacey WA 30
hry Cha Beebe 11210 Saskatoon Ln SE,Olympia,WA 98513 39
3CACT LQPATto l OSED DISPLAY
Ul N
�101 106,Union Wa 98592
No I r- 2010 aprox 6pm
UMBER ANgl(-fIDS OF FIREWO " Q BE SPLAYED
150 3"Ariel shells
fired electricaly
__ _1�3eGt to apptovai of Lal Fire f}
SI NA"� .NT E.Beebe
2010.05.1415:07:11-07'00'
FINANC14L RESPONSIBILITY'
B2NQILI!"!211INS MPANY (Mark One)
Lombined Specialties,Inc El Bond or certificate of insurance attached
- — Bond or certificate of insurance on file with State Fire Marshal
05 San Marin Drive,Suite 5 Bond or certificate of insurance shall provide mininSum coverage of
Navato,California 94945 $50,000/$1,000,000 bodily injury liability for each person and event,
respectively,and$25,000 property damage
r
T II PERMITERMIT# DATE:
In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a
firework
NAME:
RESTRICTIONS:
Permit not valid without verification of (Signature of Official orantina rmit)
the appropriate State Fireworks License
itie)
LICENSE NUMBER: 71
(Instructions on reverse side)
3000-420-050(R 02/05) Distribution: WHITE(A): Local Fire Authority; YELLOW(B): Permitee
Alderbrook Fireworks Display •
July 5th, 2010
�. Traffic More... I:fap Satellite =aa•
ios
700' Diameter
Secured Permiter
. � ;'� Barge Location
nr
t z
< a
Washington Hotel-,view Washington Hyatt com-10 Hyatt Hotels in Washington Best Rates Online Guaranteed
-- ----- — ®Internet Douote-cllcx co zrvr a secs r;se::
Certificate of Insurance
81707 Issue Date: 11/08/2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Debbie Meriino 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
Olympia Washington 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 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 INSUREDS SHOOTER(S)ASSISTANTS)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 INSURERS
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(MM/DD/YY) DATE(MM/DD/YY)
A GENERAL LIABILITY 1269542756/010 May 15,2010 May 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/OPSAGG $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 and employees as their interest may appear are Additional Insured as respects the November 26,2010(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
/k—�-
AUTHORIZED REPRESENTATIVE `