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Home My WebLink AboutFIR2004-00054 Firworks Display - FIR Permit / Conditions - 10/15/2004 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext.352 _ Shelton,WA 98584 FIRE PROTECTION PERMIT FIR2004-00054 APPLICANT: NORTH MASON HIGH SCHOOL RECEIVED: 9/24/2004 CONTRACTOR: LICENSE: EXP: ISSUED: 10/1/2004 SITE ADDRESS: 71 E CAMPUS DR BELFAIR EXPIRES: 4/1/2005 PARCEL NUMBER: 122082360000 LEGAL DESCRIPTION: SW NW E OF R/W' SEE SURVEY 9/14 71 E CAMPUS DR PROJECT DESCRIPTION: fireworks display for homecoming GENERAL INFORMATION System Information Type of Use: DIS Sprinkler Heads: 0 Audible Switches: 0 Pull Stations: 0 Fire District: 5 Flow Switches: 0 Visual Devices: 0 Door Releases: 0 Hood & Duct?: N Pressure Switches:: 0 Smoke Detectors: 0 Duct Detectors: 0 Dry Chemical?: N Zones: 0 Heat Detectors: 0 Wet Chemical?: N Sprinkler?: N Standpipe?: N SQUARE FOOTAGE FEES Monitoring Company: N/A First Floor: Type Amount Due Amount Paid Monitoring Phone No.:0 - Second Floor: Auto Fire Alarm?:N Third Floor;: Fireworks Display Permit $100.00 $100.00 Fireworks Display Permit $29.00 $29.00 Total: $129.00 $129.00 FIR2004-00054 Please refer to the following pages for conditions of this permit. 1 of 3 CASE NOTES FIR2004-00054 CONDITIONS FOR FIR2004-00054 1.) A site inspection by the F/M is required before the shooting of the show. X This permit becomes null and void if work or construction authorized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at any time after work is commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied. Proof of continuation of work is by means of a progress inspection.The ownerorthe agent on the owners behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection. // OWNER OR AGENT: �G� o� DATE:�,Z'2 FIR2004-00054 Please refer to the following pages for conditions of this permit. 2 of 3 N O O CONCRETE MECHANICAL MANUFACTURED HOME 0 c Footings / Setbacks Date B y Ribbons Op Date By Gas Piping Date By Foundation Walls Date B y Set-up Date By INSULATION Date By B G 1 Slab Insulation Floors Final Date By Date By Date By FRAMING Walls FIRE DEPT Date By Date By Date By PLUMBING Attic OTHER Groundwork Date By Date By WALLBOARD NAILING v D.W.V. Date By Date By FINAL NS ECTI `D Water Line Date d B Date ByDate By .7 M O A ° y o IA Ul �A O G� O O W a W Mason County { Fireworks Permit Application PO BOX 186 426 W Cedar St Permit # FIR Lj Shelton WA 98584 i RECEIVED (360)427-9670 ext 273 Receipt # SEP 2 4 2004 c K # ? �' 426 W. CEDAR ST: Date Received � � �`' �0If 6 rt- 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 upon satisfactory site inspection by the Fire Marshal. Applicant Information Name: STRrPF-s Mailing Address: A/W zc c-/ctt RD City: State: (,vyt Zip: qg�38 3 Contact Number 360)��Z-s2zgCrt� 3�d-476- 4s 7�3Cc�) Sponsor Information Name: o1-7'H .(ilNSo�i 1�16 tf Sc61ooL (Tu,yY dtSoNor� �iyNcg Mailing Address: Zoo E. City: _5E4F�ik State: t:,,m Zip: %8Sz8 Contact Number Washington State Fireworks License Information (Copy Required) License No.: ,015,P1.,i Y 4 t C-,F&5,Lz- Date of Issue: ® Pyrotechnic Operator License 403G ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: --- r lc c oros aF c�.Lno.v Insured: 57'RtPa-5 R2m7wlz- Certified Holder: tvb.R t ty ,c,,► s,�,v bf�6 hf S�EfooL Location of stand/display Address: '_ c. 14(r->ces OX BFLj-Aj,, 2 Directions to Site: ��v� 3 ro �,c cur-orFRp r�yRrA Mr ,9ff2,&,e 3 '7N 4-0Fr lNTo /V1Aft5 AR,CKAN6, c.oT- 3;17'0/N !"tg[O � o Parcel Number. Zo,p, - Z3 _�e000 pl9reK,.vG �,� Legal Description: Legal Property Owner: x44,c�v ccxw14r-;- �tsrre�c�- * * Please see the reverse side to complete your application 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 designated display 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 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 ��;v I� �< r Date glz.,fro FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: 0 0 ■ APPLICATION DATE OF APPLICATION PARTI WAS�N STATE PATROL FOR PUBLIC FIREWORKS DISPLAY PERMIT 2 1 s Po4 TO: Governing body of city, town or county in which display is to be conducted. APPLICANT NAME ADDRESS PHONE 36p-6 Z-8 TR! L Ws w [L•( c6f Ap, SIt.VER AL&' wsa %B38 6c- 76-8773C SPONSOR ADDRESS PHONE 69r f sc� cofAw^es c -277- 'Z 169 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# ,e 5 !L L 4A& IV A., /L c-/csV RP, t u * 12)S36 O 3b NAMES OF ASSISTANTS: at least one required) NAME ADDRESS AGE 1,L o t a cc c-7- lL eo 4 q NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION L FIEL.P 045r -F tYMHS ST /u.G► oPO l A 6 "L47- DATE /57 TIME fa �l a4 SAS 7. 30- 4W to:oo P,u < 1I0 Mear) NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED e - GL S GI5►�2" o _ zt!cam �t zap *t MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authorit ff p [w e a.6,r.Q i ,� /¢ x oie pc o .v G, T R L 3 s w G[ �G , c.w 8 6 L�'VCAc T D�ERieleK G/CAur� 6C a FivC o. 7ft/S 5/7`11V / ,-00'Q FCIA-- P&AOt-F.A%4A40 SIGNATURE OF APPLICANT 97tvp-44Z �i FINANCIAL RESPONSIBILITY BONDING OR INSURANCE CO. (Mark One) 4-_S=, Bond or certificate of insurance attached ❑ Bond or certificate of insurance on file with State Fire Marsha ADDRESS 3�2 e K V 1,L4_ 5 t¢ �l9 Bond or certificate of insurance shall provide minimum coverage of$50,000/$1,000,000 bodily injury liability for each (�0o08�lPY, A0CWti4N 5-5-1 ZS- person and event, respectively,and$25,000 property damage PART II PERMIT PERMIT# FT\�QtH "' DATE: C74:z 42�e, 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 tapplication. NAME `�'t�<�U p S 2e_. C�, (Full name of person,firm or corporation granted permit) RESTRICTIONS: -Q670 eit , 12 �Z� Signature orbffical granting permi) Permit not valid without verification of State General Display License (Title) LICENSE NUMBER (Instructions on reverse side) Distribtuion: WHITE(A): Local Fire Authority; YELLOW(B): State Fire Marshal's Office; PINK(C): Permitee 3000-420-050(R 01/01) INSTRUCTIONS APPLICANT .'.:Corrffpleld;Aart I of the application and present all three copies to the Chief Fire Official of the city,town or county in which the display is to be `•>held.:if OL SPecial P.ubtic D11001 p License is c6AWA t'Plat&d,atf@ch clgWMentary pnef.of a surety 6ond:or a certifictite of pubrti liability insurance covering the time period of the display. If the applicant already has a General Display License for displays at various locations,indicate thata pond er,(ewtificateo€'insuxfih.yeis on fifewith the,GWe.Fifi6friarshal,couering1hedate and location of-the display. r General Public Display Licensees retain Copy"C"of the comptieted application and return Copy"B"to the State Fire Marshal's office,210 11th Avenue 3(N,Post Office B<3x,42�0€1;Qlym�ia,:1N��35Q4-2600. Wnot+already,irr•possession of a General Pub WDisplayLicense, forward copes"B"and"C"along with the$10.00 Special Display License fee, to the State Fire Marshal's office. Upon receipt by the State Fire Marsha's office,the license of the Pyrotechnician will be verified and a Special Public Display License issued. Copy"C"and the license will be returned to yob,which will authorize:the.pur9han ofShe staeriial fire+�orks listed gn the app7ic@tion.. tao y"C"shall be maintained at the a play site and made available to local or state officials to verify the Permit and License. CHIEF FIRE OFFICIAL/GOVERNING BODY r Determine that the applicant is in possession of a current State Public Display license,and that the Pyrotechnician holds a current State Pyr4teghnician5 ficf.nse. ._ 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 the event that htis authority has been delegated to you,issue or deny the permit. If approved,the governing body or fire official should complete Part it of the Application and retain Copy"A"plus the documentary proof of 4 insurance,and return the othercopies"B"ando�"C".of•the.Appkcation to theapplicant: FIREWORKS WHOLESALER Possession by the appiicant•of...CJ"C"of the compieted Application,sigped bythe local issuing authority.along with the license issued by the State Fire fviarshai,shall seryA;�s,authorization to the.wholesaler to sell the applicant the Special.F,i v✓orks listed on the Application,for'use at tfie d"ate and IocatTon specified. The Pyrotechnician's report,required to b"Ied bh the•py_rptechniaan within ton days following the display,will be retained by the State Fire Marshal,along-with Copy',B"of the application,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 Greworks�6,oc anypegligence.Qn lhekpact of the-applicant,or their agent,servants, employees,or sub-contractors in the presentation thefeof.'ot 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-alto i to-respond-intiamag es,: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-rriillion dollars for bodily injury liability for each person and event,respectively,and oot 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 irldividuai,-c9ncern,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 shail-be filed with the State Fire Marshal.' The bond or certificate evidnencing public libility of insurance in a like amount shall provide that:(a)the insurer wil 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 aniridependent contrator and the State of Washington,its officer,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 arty premium assesments 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. Sep 22 04 09: 19a Debbie Merlino 415-209-0013 p. 5 Certificate of Insurance 386705 Issue Date:09/22J2004 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Combined Specialties International,Inc CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE 8362 Tamarack Village DOES NOT AMEND,EXTEND OR LATER THE COVERAGE AFFOROCO BY THE Suite 119 POLICIES BELOW. Woodbury M nngypta 55125 INSURERS AFFORDING COVERAGE INSURER A:Underwriters,Lloyds of London INSURCO INSURER B: Striaea Retail,Inc. IN$UR[R C. Fireworks Supermarket,dba 579 NE Renud Lane Bremerton Washinoton 98311 INSURER D. COVCRAGCS 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$UBJCCT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES INCLUDING.BUT NOT LIMITED TO THOSE FOLLOWING:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ADDITIONAL CONDITIONS AND EXCLUSIONS:1)THE INSURANCE EVIDENCED BY THIS CERTIFICATE IS LIABILITY INSURANCE ONLY,IT IS NOT A BOND OR ANY FORM OF SURETY AGAINST WHICH SOMEONE OTHER AN"INSURED"MAY ASSERT A CLAIM OR BRING ANY ACTION,SUBJECT TO POLICY TERMS,CONDITIONS,DEFINITIONS AND EXCLUSIONS THE INSURANCE ONLY INDEMNIFIES AN INSURED AGAINST CERTAIN LEGAL LIABILITY.2) THE INSURANCE DOES NOT COVCR CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE OF THE NAMED INSUREDS SHOOTCR(S)ASSISTANT(S)OR ANY OTHER PCRSON(S)INCLUDING ANY VOLUTEER(S)PARTICIPATING IN ANY WAY IN ANY DISPLAY OR SPECIAL EFFECT PERFORMED OR LXECUTLD BY THE NAMED INSURED.3)COVERAGE DOES NOT APPLY TO CLAIMS FOR BODILY INJURY OR PROPERTY DAMAGE ARISING OUT OF THE INSURED's FAILURE TO FOLLOW NFPA OR OTHER APPLICABLE REQUIREMENTS,LAW$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 LTRDATE(MM10DlYY) DATE(MWDD/Yy) A GENERAL LIABILITY CLAIMS MADE 1091120086/004 Jwly 29,2004 July 29,2005 EACH ACCIDENT $1.00,000 MEDICAL CXP(ony Oro S5,000 person) FIRE LEGAL LIABILITY $50,000 GENERAL AGGREGATE S2,000,000 PRODUCTS-COMPIOPS S1,000,000 AGG AUTOMOBILE LIABILITY ANY AUTO ANY COMBINED SINGLE LIMIT(Ea $ OWNED AUTO SCHEDULCO AUTOS HIRED accident AUTOS NON-OWNED AUTOS BODILY INJURY Per person 3 BODILY INJURY(Per S accident) PROPERTY DAMAGE(Per 5 person EXCESS LIABILITY FOLLOWING FORM EACH ACCIDENT S AGGREGATE S WORKERS COMPENSATION AND WC STATu- OTHER TORY EMPLOYERS'LIABILITY LIMITS E.L.EACH ACCIDENT $ E.L.DISCASI!<A 5 EMPLOYER EL DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATION$/LOCATIONS(VEHICLES/ExCLU$rONS ADDED BY ENOORSEMENTISPCCIAL PROVISIONS Cerlircate holder is additional n3ured as respects a fireworks d,sp:ay on OclobeF 8,2004 at Balfield located east of Parking Lot e3St of North Mason High School Campus CERTIFICATE HOLDER CANCELLATION North Mason High School SHOULD ANY OF THE ABOVE DESCRrBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 200 E.Campus Or, THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE Belfmr,WA 98526 CERTIFICATE HOLDER NAMED TO THE LCFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,IT'S AGENTS OR REPRESENTATIVES AUTHORIZED REPRESENTATIVE /) 240' BLEACHERS NORTH NORTH MASON HIGH SCHOD)4 35' BASEBALL FIELD FOOTBALL STADIUM PARKING LOT 190' 160' 00' 340' CLASS C BLEACHERS "CAKE" ITEMS 220' 125' ............................................ FENCING 22' SITE PLAN C L ASS "C" CONSUMER 262' FIREWORKS DISPLAY NORTH MASON HIGH SCHOOL FOOTBALL STADIUM MASON COUNTY TAX PARCEL 122082360000 VICTOR CUTOFF ROAD cF) I LO 1 LO LLl r5 LU I CU U ►a ai ! 1- o Cr N L L y O N a W M ClO ate+ O C� U Lam' t C) 1. :C 6 0 @ r d C Q V7 w _C C? o. C F� W a' �f � W ca i. W LU _ m 00 co W r.i .O �° �► N2 �� Ln Na) N o o z I m W f— W Sin QU W > JZ� U W F V JQ o W O J +rl�m U VIL N G i Washington State Patrol 3645 Fire Protection Bureau Office Of The State Fire Marshal Washinl4ton State Fireworks License General Display License General Display: Stripes Retail Incorperated 579 Northeast Redbud Lane Detach this wallet card and carry with you for Bremerton, WA 98311- verification of certification. in State Representative: Christopher Williams Washington State Patrol 3645 Fire Protection Bureau Phone Number: (360) 692-8228 Office Of The State Fire Marshal I General Display: Stripes Retail Incorperated License Number: C-04165 Date of Issue: Date of Expiration: License Number: Tyne or License: General Display Phone Number: (360)692-8228 Tuesday, February 03, 2004 January 31, 2005 C-04165 >x irati( 4 )are: January 31, 2005 1- 3000-420-012 (R 11/00) Authorized, gnature Licensee sinnatarc