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Home My WebLink AboutFIR2007-00025 - FIR Application - 7/6/2007 NA,,a� on County Fireworks Permit Application PO BOX 186 Permit # FIR r,40d �1.1 ' h 426 W Cedar St - -�-- MASON CCUIN71 r L Shelton WA 98584 Receipt # DATElIT-L9-00:4B'?' C(360) 427-9670 ext 273 SUBJECT TG F!F!� �GTl:�x�l � CK # � J ALL APPLICAAL CODES SHALL .APPLY. EAROAS Date Received ANSI?ny OAI,MON"ON PLANS ARE SOLE nE- SPON Itt L"ry OF OWN Fovr.,-"Tn"CTOR. CCRPEC- — Tit Nx v01b ht:i4 ^P<4" =IEi 0 I12S91ECTION SHALL �J•� a'". c �:.:r LtiIL11NT:f ;•c f~ ' !.r- `(� uOFS N0 �«� � Y c�:. 1?dr►zatt fbr tbe TZi�fail dales or Public display cf fireworks is required_ A c®m �w�-- ---� -ap{�lication wish req.uir-eil documentation and fees shall be submitted fior Fir 1w 4 review. A permit will be issued upon satisfactory site inspection by the Fir> larsQ. QpQ` Applicant Information ' Name: Enr tainmi-nt Fi ewnrks, Tnr ZIP— Mailing Address: Po Box 7160 City: ni=pi a State: WA Zip: 98507-716a. Contact Number (360 ) 352-8911 Sponsor Information Name: Alderbrook Resort & Spa far Adrian—unh4en �a,il�y 4, 2007 Mailing Address: 10 F Al c3Prbronk nr City: Union State: WA Zip: 98592 __- Contact Number ( 360 )898-5527 Washington State Fireworks License Information (Copy(Required) License No.: C-04085 Date of /".'10-�� Issue: pyrotechnic r for License ® Firevworks Stand License O _ Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: see Attached _ Insured: Certified Holder: eh Location of stand/display Address: 7101 E. State Route 106 Union - Alderbrook Resort & Spa Directions to Site: Take Hwy. 16 West to Gorst, then go South on Hwy. 3 to Belfai . South of Belfair turn right on Hwy 106 & Go 15 miles to Alderbrpok Parcel Number: - - 322335000014 Legal Description: sunny Beach Tr 8-11 EX and Tax 895 See SP #- 1664 Legal Property Owner: * * Please see the reverse side to complete your application I ti ' The following 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 d esignated display areas to: • Fire Hydrants 0 Property Lines • Buildings 0 Parking • Combustibles • Public Roads and Right of Ways • Fire Lanes • Private Roads and Right of Ways • Trees / Brush • Landmarks • Utilities and Gas • Mortar separation distance • Designated la-uding area Applicants Affidavit I certify that the information providedl herein is accurate and that cornpliance with all County, S e and Federal laws pertaining to the sales or discharge of fireworks shall be ain in d 07 Signed Date _�-o ---- OFFICIAL USE ONLY BEI,OW THIS LINI E — --- Accepted By: — - - -- - - Date: ---- — - - oo®® APPLICATION PAw115NINGNN ST1TE MTROL * . DATE OF APPLICATION w r FOR PUBLIC FIREWORKS DISPLAY PERMIT 6-26-07 TO: Governing bodyof city, town, or countyin which display is to be conducted. APPLICANT NAME ADDRESS PHONE Entertainment Fireworks, nc. PO Box 7160 Olympia WA 98507-7160 360-352-8911 SPONSOR ADDRESS PHONE Adrian Hobden Family 177 E Ensign Vista Dr Salt Lk City UT 84103 PYROTECHNIC OPERATOR NAME ADDRESS G Ll 3 0 LICENSE# Ryan Greenly �14520 254th Ave Monroe WA 98272 P-04309 OF ASSISTANTS: at least one required) NAME ADDRESS a- 3 a AGE J Larry Mattingly 1113 132nd E Tacoma WA 98445 P-02701 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION Pier at Alderbrook Resort & Spa, 7101 E St Rt 106 Union WA DATE TIME July 14, 2007 Dark Ap rox 10:15 PM NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED 2.0" Salutes - 5; up to 3.0" Comets - 8; up to 2.0" Roman Candles - 4; up to 2.5" Cakes - 3; 2.0" Aerial Shells - 25; 2.5" Aerial Shells - 25; 3.0" Aerial Shells - 87; 4.0" Aerial Shells - 25; .75" Roman Candles - 103. MANNER&PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) Delivered to site day of display. IG TU E F PPLI ANT, FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) Britton Gallagher & Associates ® Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal Bond or certificate of insurance shall provide minimum coverage of 6240 SOM Center Rd. Cleveland OH 44139 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II PERMIT PERMIT# DATE: In 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: C-04085 (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee INSTRUCTIONS , APPLICANT Complete Part I of the Application and present both copies to the Chief Fire Official of the city, town,or county in which the display is to be held. If a Special Public Display License is contemplated, attach documentary proof of a surety bond or a certificate of public liability insurance covering the time period of the display. If the applicant already has a General Display License for displays at various locations, indicate that a bond or certificate of insurance is on file with the State Fire Marshal, covering the date and location of the display. General Public Display Licensees retain Copy"B"of the completed Application. Copy"B"and the license will authorize the purchase of the special fireworks listed on the Application. Copy"B"shall be maintained at the display site and made available to local or state officials to verify the Permit and License. CHIEF FIRE OFFICIAL/GOVERNING BODY • Determine that the applicant is in possession of a current state fireworks license and that the Pyrotechnician holds a current license. • Make an investigation of the proposed site to determine whether the display will be hazardous to property or dangerous to life. Exercise reasonable discretion in evaluating fire hazards,vehicle parking,crowd control,storage prior to display,and general precautions against fire,explosion,or panic during the display. (Use of NFPA 1123 Public Display of Fireworks is recommended for guidelines.) Submit your findings and recommendations to the governing body for final decision or, in the event that this authority has been delegated to you, issue or deny the permit. • If approved, the governing body or fire official should complete Part 11 of the Application and retain Copy"A"plus the documentary proof of insurance,and return Copy"B"of the Application to the applicant. FIREWORKS WHOLESALER Possession by the applicant of Copy"B"of the completed Application,signed by the local issuing authority along with the license issued by the State Fire Marshal, shall serve as authorization to the wholesaler to sell the applicant the Special Fireworks listed on the Application,for use at the date and location specified. The Pyrotechnician's report, required to be filed by the Pyrotechnician within ten days following the display,will be retained by the State Fire Marshal as evidence of the display. RCW 70.77.285. FILING SURETY BOND OR CERTIFICATE OF INSURANCE. The applicant for a public display of fireworks permit shall, at the time of the application,file with the officer to whom the application is made,a bond issued by an authorized surety company to be approved by such officer,conditioned upon the applicant's payment of all damages to persons or property which shall or may result from or be caused by such public display of fireworks,or any negligence on the part of the applicant,or their agent, servants,employees,or sub-contractors in the presentation thereof,or a certificate of insurance evidencing the carrying of appropriate public liability insurance for the benefit of the person named therein as assured,as evidence of ability to respond in damages in at least such amount,said policies to be similarly approved. RCW 70.77.295. AMOUNT OF BOND OR INSURANCE. In the case of an application for a permit for the public display of fireworks,the amount of such a surety bond or certificate of insurance shall be not less than fifty thousand dollars and one million dollars for bodily injury liability for each person and event, respectively,and not less than twenty-five thousand dollars for property damage liability for each event. RCW 70.77.355. ALTERNATIVE PROVISIONS FOR GENERAL LICENSEES. (1)Not withstanding any of the other provisions of this chapter relating to public liability insurance and bonds,any adult individual, concern,firm,corporation,or co-partnership may secure a general license for the public display of fireworks within the state of Washington subject to the provisions of this chapter relative to the securing of local permits for the public display of fireworks in any city or county, except that in lieu of filing the bonds or certificate of public liability insurance as required in RCW 70.77.285 and 70.77.295,a surety bond similarly conditioned or a certificate evidencing public liability insurance in a like amount shall be filed with the State Fire Marshal. The bond or certificate evidencing public liability of insurance in a like amount shall provide that: (a)the insurer will not cancel the insured's coverage without fifteen days prior written notice to the State Fire Marshal; (b)the duly licensed pyrotechnic operator required by law to supervise and discharge the public display,acting either as an employee of the insured or as an independent contractor and the state of Washington, its officers, agents,employees,and servants, are included as additional insured, but only insofar as any operations under contract are concerned;and(c)the state is not responsible for any premium assessments on the policy. (2)The State Fire Marshal shall have the authority to issue such licenses, subject to such reasonable rules and regulations which he or she may adopt, not inconsistent with the provisions of this chapter. A certificate evidencing such general license,when so obtained, shall be filed with the legislative body or officer granting a permit for the public display of fireworks prior to the issuance thereof.