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HomeMy WebLinkAboutFIR2007-00010 - FIR Application - 5/30/2007 -- , - ason County Fireworks Permit Application MASON CG_ FAO BOX 186 Permit # FIR ae03 Q►2` DATE 13e:off- c 426 W Cedar St SUBJECT TO i;. ,�N Shelton VIVA 98584 Receipt # ALI- APcLICARL CODES SHALL. APPLY. FHROR:; (360) 427-9670 eXt 273 AND/OR CMISSIpUS ON PLAt^S ARE SOLE O CIE- CK # SC'ONSISILITY F O+'rVBRiCG^:T,+^'GTOPi. CORREC- TIONS'REQUIRED FRUIT FIELD It15PECTION SHALL. BE AT L DOES RANT T C:{PE^;SE. THIS AP- Date Received OS—I�- �Ob�AP- PROVAL DOSS NOT GRANT TO :'2'+ Pf�.iiS(�N THE _ RIGHT TO VIOLATE ANY CITY O.': STAT LAZY;;. A Permit for the 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 up►an satisfactory site inspection by the Fire Mairshal. Applicant Information Name: EntPrta i nment- Fi rPwr„-><--., Tnr Mailing Address: Po Box 7160 City: e1 wni a State: wA Zip: 985107-71Fn. Contact Number (360 ) 352-8911 Sponsor Information Name' Alderbrook Resort & Spa Mailing Address: 10 F AIderh monk Dr_ , City: Union State- WA _ Zip: 98592_._.___ Contact Number ( 360 )898-5-527 _ z Washington State Fireworks License Information (Copy(Required) ' License No.: C-04085 Date of 1/30/07 Issue: xj Pyrotechnic Operator License El Firewworks Stand License I' P-04241 Aaron Kul - m ffDa 3k6 ado- 99,D) _ �J Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: See Attached -- Insured: Certified Holder: Location of stand/display Address: 7101 E. State Route 1106 Union - Alderbrook Resort & Spa Directions to Site: Take Hwy_ 16 Mest to Gorsst, then go South on Hwy. 3 to Belfai South of Belfair turn right on Hwy 106 & Go 15 miles to Alderbrook Parcel Number: _ - - 3223350070014 Legal Description.- Sunny each Tr 8-11 EX and T'ax 895 See SP # 1664 Legal Property Owner: * * Please see the revers{✓ .sid a to complete your application � '� The following ertinent information MUST be provided on the site diagram below pdesignated ions and Setback distances from the back, sides and front of retail sales stands or dis la areas to: Fire Hydrants • Property Lines • Buildings • 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 landing area Applicants Affidavit I certify that the information prcDwidedl 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 �fl, ° ,��.��- �,t , Date �_ — ---- FOR OFFICIAL. US E ONLY BELOW TH IS Ll INE -- Accepted By: iDate: _ __ 000®WASHINMN STAW WROL APPLICATL,ON DATE PART I nn� 't - O �� FOR PUBLIC FIREWORKS DISPLAY PERMIT 'PPLICATION '© TO: Governing body of city,town, or county in which display is to be conducted. APPLICANT NAME ADDRESS PHONE Entertainment Fireworks, Inc. PO Box 7160 Olympia WA 98507-7160 360-352-8911 SPONSOR ADDRESS PHONE Alderbrook Resort & Spa 10 East Alderbrook Dr. , Union WA 98592 360-898-5527 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Aaron Kul � 9148 Shadberry Dr. OlyLnpia WA 98513 �P-04241 NAME OF ASSISTANTS: at least one required) NAME ADDRESS AGE AnthonyVain 9148 Shadberry Dr. , Olympia WA 98513 29 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION From stationary dock at Alderbrook Resort & Spa/ 7101 E. St Rt 106 Union, Mason Ct DATE TIME #322335000014 NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED 2.0" & 3.0" Salutes - 15, 2.0" & 3.0" Comets - 15, 3.0" Mines - 9, Roman Candles up to 2.0" - 11, Multi-shot Cake Devices up to 2.0" - 3, 2.5" Aerial - 20, 3.0" Aerial - 120, 4.0" Aerial - 125, 5.0" Aerial - 9 MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) Delivered to site day of display. SIGNATUR O APPLICANT o 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# / -Z00-7 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 1 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 a 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.