HomeMy WebLinkAboutFIR2004-00065 Hood and Duct - FIR Permit / Conditions - 4/14/2015 Mason County
Fireworks Permit Application
PO BOX 186
426 W Cedar St Permit# FIR�Qoq--
Shelton WA 98584 Receipt # ��
(360) 427-9670 ext 273 p �
CK #
Date Received -�q "fA
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: , �
Mailing Address: �� T
City State: Zip:
Contact Number (36„ )
Sponsor Information
Name:
Mailing Address:
City: Stater Zip:
Contact Number ( )
1
Washington State Fireworks License Information (Copy Required)
License No.: Date of
Issue:
❑ Pyrotechnic Operator License Fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider:
Insured: 1�.2✓�� ��,���c
Certified Holder: 4/,, e� ,1-0171 �� <
Location of stand/display
Address: 36 s, / S
Directions to Site: t z r ;z
Parcel Number: 32
Legal Description:
Legal Property Owner: P
* * Please see the reverse side to complete your application
The f6flowing 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
-desighated.display areas to:
• Fire Hydrants • Property Lines
• Buildings • Parking
• Comb wtibles • 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
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Applicants Affidavit
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 b ined. '
Sign �9�' Date
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date:
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Washington State Patrol
Fire Protection Bureau
Office Of The State Fire Marshal
Washington State Fireworks License Fireworks Stand License
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Licensee Information License Is Non-Transferable And Valid For One Stand
N Dave Cooper2:-L- �z 41:A
Post Office Box 1436 Date Of Issue: February 17, 2004 Stare bi orization
Del ach this wallet card and carry with you for
w Tacoma, WA 98401- Expiration Date; January 31,2005 verification of certification.
Stand Information Washington State Palrol 3745
Contact Person; Dave Cooper Fire Protection Bureau
-' p Offke Of The State Fire Marshal
Phone Number: (360)377-4100 County Kitsap FIRMVORK STAND LICENSE [Yatid For OoreStand]
MemoLicense Number: WSPFL-00212 Stand License Number: SN-0000278 DavetGoop _t.' -;`
rontaer Penao: Da;T�Cr�er
Stand Number; SN-OMQ Y9?� ~F &e-Nvmher.WSPFL-00212
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Facairatim 1)ate: lamreq
Strand Location: [.acaRon; �.. _ -
[Stand Location To Be Completed By Licensee] Isr t.k"*7C0vepreea?bylt4-1
311fN1A7f1 f1 7 rR 1 I/tN11 . Aulhmized SAmiture Liceastee sinnatue
11/24/04 11:38 FAX 1 253 922 0295 PYRODYNE SALES Z 002
DRAYT'ON INSURANCE BROKERS, INC.
2$o0 CENTER POINT ROAD,SL'TT]E 301
BIRIENGHAIGI,ALABAMA 3521S POST OFFIC$BOX 9406^
TELL-PHONEi (205) 854-5e06 BMWNGRAM,ALUMMA 35220
FAX, (20s) 954-5699
CERTIFICATE OF INSURANCE NO,
'We certify that insurance as outilned below is afforded the Namcd Ins.lred under policy No.CAOM00 1 8 58-1 6 isst;ed by Admi'al Insurance Company.
NAMED INSL'Ri;D American PPOmOtion01 Events,Inc,
rL'bia TNT Fireworks
P.O.Box 1318 Certificere No, 521194
Florence,Alabama 3563 1
PERIOD November 1,2004 10 October 31,2005. Both Days Inclusive,
COVERAGE Commercial Gcnerai Llability including Premises&Operations Liability and
Products&Completed Operations Liability
LIM[T OF I,IABILITY Each Occurrence
Products Aggregate $1,000,000
General Aggregate S2,000,000
52,000,000
1t is certified that, in accordance with,and subject to,the terms of the above policy the following SPONSORS AND/OR COMM 1TTLES AN
PROPERTY OWNERS AND/OR LICENSM AUTHORITIES are inctud D/OR
cd as Additional Insured(s),but Only in respea of the legal habi
such Additional Insureds)for Bodily Injury and Property Damage arising out of: I)the ownership or use of Lte Insured premises sorted bdiow.
which urc usod for the sale of fireworks distributed by the Named Insured.2}[hc sale by tht Additional Insured orfira d l"rerks disesbated by the
Named Insured The l;te b of liability stated above shag!not be increased either; 1)by the inclusion of more than one Insured;nor 2)by the receipt of
more than one certificate by any Insured,
INSURED PR.EVIISES:
Locution No, WWM6514
CRAZY ERICS
33101 HWY3
BELFAI&WA
ADDITIONAL INSlJUj)5:
A1ASON COUWTY
CRAZY ERICS RESTAURANT
DAYE,COOPER
Their ofYtcers,agents and employees when acting in their o,licia!cappcites as such,
Notwithstanding any requirement,term or condhion of any contract or other document with respect to which this certificate may be issued,or may
pertain.the insurance afforded by the policy described herein is subject to all the tom%%exclusions,cad conditions of such policy. For particulars
concerning such terms,exclusions and oonditiurns each Additional Insured is referred to the policy documents in the possession of the'yarned
Insured_ Should the above described policy be cancelled before the expiration daft thereof;rile issuing company will mail 30 days'prior written
notice to the above named Addhicrel Insured,
1!r 24;04 DRAYTON fNSUR4NCE BROKERS,INC.
DATE OF ISSUE A� SCRINGER, PRESID
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