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Home My WebLink AboutMIS93-0279 Fireworks Booth - MIS Application - 7/6/1993 MIS `�3-Oa`� MASON COUNTY MISCELLANEOUS PERMIT APPLICATION 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670 PLEASE PRINT #1 Owner 571�ODk_) A v Phone # Fire District# Z- Site Address 7�Jy 3&D City Mail Address City St Zip Applicant illUDIO&ER F Phone # 2C�6— q?5� e32-7/ Applicant Address J a City St Zip / �3 Directions to Site: #2 Parcel No. 11—:15 -_ 1 (90 t 106 Legal Description #3 Indicate by circling the applicable source if any water is on or adjacent to the property site: saltwater lake river creek stream pond wetland seasonal runoff marsh other #4 Project Start Date 2-D/5� Project Completion Date 7/6 LC(i5 PP 0� #5 Use of Buildiing Describe proposed construction "Depending upon the type of permit,a floor plan and plot plan may be required. 'This permit is valid for 180 days from the date of issuance. OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON- MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT- ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE- FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST WITHOUT FIRSTOBTAINING APPROVAL FROMTHEBUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART- ING DEPARTMENT. MENT. X OWNER X BY DATE DATE Show following on the site plan Lot Dimensions Flood Zones Existing Structures Fences Structure Setbacks Wells Water Lines Shorelines Drainage Plan Easements Septic Systems . Name of Fronting Street Indicate directional by Proposed Improvements Name of Flanking Street N, S, E, W etc. PLOT PLAN AREA FOR OFFICIAL USE ONLY: Accepted by: Date: DEPARTMENTAL REVIEW FOR OFFICIAL USE ONLY Planning APP COND APP HOLD Building Fire Marshal -OK(2W76W ` Other Special Conditions Fees 6 �de I\VJA r` W ✓ Permit Fee $ Plan Check Other Other State Building Fee TOTAL DUE $ •------- MASON COUNTY FIRE MARSHAL No 0012 wwtf (tS5 P.O. Box 186 Shelton,Washington 98584 DATE OF APPLICATION 427-9670 _ -qq MIT Department DATE f' ��' 19,, \\ d. , Port Orchard Receiv�Idlflm • 50 00 Fire Alarm System 25 00 Sprinkler System 50 00 Fixed Fire System 10 00 DSED OF BEFORE JULY 31ST) ' Fireworks YATL.PE OF APPLIC NT Penalties :-" .........................................................---'--..."--...-'---.-.. .-'-------'•' Miscellaneous 1993 dear open to the public) authority and a license by ••"• hereby authorized to sell 1 the hours of 12 noon on ❑CASH ❑MONEY ORDER $ 77. ' CHECK 5c1� Department Head elfair, WA Deputy THOMAS PRINTING,SHELTON,WA ��`��. Ire of 0 c ssuing License Licensing Division Agency OFFICE OF STATE FIRE MARSHAL C� Olympia, WA 98504 Date 6 ' m Permit # AS 3 -0 a 79 Date s-/D - 93 License # D 7 PERMIT NOT VALID UNLESS SIGNED BY BOTH LOCAL AUTHORITY AND STATE FIRE MARSHAL ��,.��,. ••:•i;•iiS..i`.N,;: .;. rr. �.. •�, ,�. rr ,... •�, ,�, rrr, �.� •�, .,��rrr.• �.... .,.. rrr f ,..� �" ,�. �.��:�...�.�.` �'��•��•�.%;r�','��dCi��i.. .�i.i;;i%•;r:'•`��••��:!T !�!i�iiii�i;:':,�N•.��i�' �•i•i•iiii:Y�11��ii��.i.. ••�r�•••rr„':d�•••..�•�. •r•••• .�,..,�� 1%; ♦..;• ,�.•♦ •. � rrr ,:.• • .r!!.i,ae• •a,.>��. .!!�qt< •``...�.•••�•�. ••�•4•�9y„ .:..�.••�•�.' '•!!iii.,;: ,�.`.•.•.�i!� '.�•�,►,rirrr! d,`.,.i•�.:i%iril,�,. AUTHORIZATION TO PURCHASE CLASS C COMMON FIREWORKS Possession by the applicant of this completed application, signed by both the local issuing authority and the State Fire Marshal, authorizes the applicant to purchase Class C common fireworks for retail sale from the supplier shown at the location indicated. COPY "A"-Applicant (instructions on reverse side of form) Form SF 601 QX A-252 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 TELEPHONE: (205) 854-5806 FAX: (205) 854-5899 CERTIFICATE OF INSURANCE We certify that insurance as outlined below is afforded the Named Insured under Policy No. A92EG19499 issued by Admiral Insurance Company. NAMED INSURED: Pyrodyne American Corporation Certificate No: Humdinger Fireworks 351170 American West Marketing, Inc. Freedom Fireworks, Inc. P. O. Box 1436 Tacoma, Washington 98401 PERIOD: November 1, 1992 to October 31, 1993; Both Days Inclusive. COVERAGE: Commercial General Liability including Premises&Operations Liability and Products&Completed Operations Liability. LIMITS OF LIABILITY: A) Each Occurrence $1,000,000 B) Products&Completed Operations Aggregate $1,000,000 The above stated limits of liability apply to each occurence but, as respects Products and Completed Operations liability only, in the aggregate. It is certified that in accordance with, and subject to, the terms of the above policy the following SPONSORS AND/OR COMMITTEES AND/OR PROPERTY OWNERS AND/OR LICENSING AUTHORITIES are included as Additional Insured(s), but only in respect of the legal liability of such Additional Insureds for Bodily Injury and Property Damage arising out of, 1) the ownership or use of the Insured Premises stated below, which are used for the sale of fireworks distributed by the Named Insured, 2) the sale by the Additional Insured of fireworks distributed by the Named Insured. The limits of liability stated above shall 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 PREMISES: Location Id: WWH-6 5 5 0 STAND LOCATION - SANDY' S HIGHWAY 3 & HIGHWAY 300 BELFAIR, WA ADDITIONAL INSUREDS: MASON COUNTY JIM STRODE / CAL BAINES 2497 ALASKA AVE E PORT ORCHARD, WA 98366 their officers, agents, and employees when acting in their official capacities as such. 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 policy described herein is subject to all the terms, exclusions, and conditions of such policy. For particulars concerning such terms, exclusions, and conditions each Additional Insured is referred to the policy documents in the possession of the Named Insured. Should the above described policy be cancelled before the expiration date thereof, the issuing company will mail 30 days' prior written notice to the above named Additional Insured. DRAYTON INSURANCE BROKERS, INC. 05/03/93 DATE A. . STRINGER, PRESIDENT Numdin er Fireworks w!N M Cp SSQ ACOUNT NAME 9 ORDINANCE OF: Maso o. _ -------------------------- CHAIRMAN:__ BOND AMOUNTS _ � ----- � -------- ------- TELEPHONE:___________________________ SETBACK REOUIRMENTs --------------- STANDADDRESSs ----------------------- ----------------------------- ---- ----------cnrn^r jjt—a-&-& W---------- STAND NOTESs FACESs SHOPPING CENTER 7Y AND STATE: gelrafr;—"Wa:----------- ---------------------------- --------------------- LROSS STREET: ---------------------- ---------------------------------- ------------------------ ---------------------------------- axsaasamsass:seasseasisssasssasssssasassasassssasasssssssasssssssssassssxasa CONTACT/MANAGER______________________ STAND SIZEs 24' CONTACT SINGANTURE DATE UPs -------------------------- CREWS "--------------------------- --------------------- ------NOTES ----------------------------- _____________________ ____ DATE DOWNS ------------------------------------- CREWS ------------------------ ------------=---------------- cxx=:asssssxasas=osssssaassasasssaasa==as=asassssssssssssssssssssassssssss NORTH 1 r ds • l�y�� 'E r�fp y.. 9854+� rT ` 1 s�yw s 0 : D o r MAY 2 01993 May 19, 1993 GENERAL�ERVICEE Mason County Fire Marshal Attention: Dave Selzer b P.O. Box 186 �Ik Shelton, WA 98584 Dear Dave: Please find enclosed a state license/permit application, insurance certificate, and site diagram for the 1993 fireworks season on behalf of the following organization wishing to run a stand in Mason County: 1. Jim Strode/Cal Baines WWH-6550 =� o� Also enclosed is a check in the amount $10.00 to cover the permit fee. Doug D'Olivio.-_� from Humdinger Fireworks will be calling you with the parcel number for this group. He has been unable to reach the property owner, but is still trying and will call you as soon as possible. If you have any questions or need further information,pl e umdinger Fireworks. Thank you for your assistance. Sincerely, HUMDINGER FIREWORKS Qnn Ransier Licensing & Insurance Enclosures: a/s /ar 4801 DUNBAR DR. N.W. • GIG HARBOR, WA 98335 206-851-8271 APPLICATION DATE OF APPLICATION FOR RETAIL FIREWORKS STAND PERMIT TO: Governing body of city, town or county in which fireworks stand will be located WWH-6 5 5 f) APPLICANT NAME Pyrodyne American Corporation DREss P. O. Box 1436 L 'Tacoma, WA..,98401 SPONSOR(IF OTHER THAN APPLICANT) ADDRESS , STRODE, JIM / BAINES , CAL Same as above . I LOCATION OF PROPOSED FIREWORKS STAND I HWY 3 & HWY 300 - BEI:F'AIR , WA FI:Lt Gury MANNER 6 PLACE OF STORAGE PRIOR, DURING& AFTER SALES DATES As per state and lo4al re> (-)l.ations . FIREWORKS SUPPLIER yr0 . erne -American Corporation (ALL FIREWORKS MUST BE RETURNED TO SUPPLIER OR OTHERWISE 611SPPS D Y ATURE OF'APPL CAN I ..............'--'......................'.................-...........................................-.................................................................................................................................................................................................... i I 4 %�/�/ji j. yi,••\•�\��ii. ri.�ij iii. .�i•�••••\�\��:,iiil�is jii. .�i•�•••�\�\`i2, iir�i///jii. .Qi�••••\\\�i'.iii iii/�/i i. .�:•:�••\\\�c. 'ii rL•I/•i. .i�• •\\�OCC�r. ` �/•i�//I•' i\\\••iir�\''':iii i��/I/i .\\\••iii�i"':iii i�///i \ \ iii. II/ •\\\' 11// • \ !II/1/ r / •/. \ ••\\�. �r�. .�.\.• '. ,`\•• is iii•.. .//•% �\\\\•. ''ii• .�/r/•. �\\\•iiii�::�i:iiii�.//•% �`\i/////%, .\\\iii�w•�. !•f�•. !r,. .!• .•�iCiG,iriij (,:'• ``!• iCi<,,iSii • !If:• .,�:' iCd:.J:'Ii !�:• `y�:•'• iCil.,'riii•• �:, �•�•••iCil.•>'I:i'••, !�:'• !•��•;/ `•`• \•A•�•� j ..J:'S•,':;% ;�4\i\\i..,Iiii/�/�'••:;% ':1�i�:\\i..,r�I/��i$.,•.; •�ti�i\\.,..Irrrifii•.':: ';��i�:\\i„ r�.��ii•.':; ':\\ii\\.�.,rri/i:�i/I•,':: 'i�/•.%'•� :�!:'::�•. f 4•i. i.,. .�`\,�...�..r....�r�,i, �,,•�...�..q.••!/err ,,\`,��Nd,.tR4!rr/r ,�\,\�...?..r..t.�r�,i, �,,\��..>..q..,!rfl;•; -•iii:'• ��•• 'i PERMIT =" Year 1994 (Must be conspicuously displayed at all times stand is open to the\ ublic) - Ii•iii•. .�.,..'�� By virtue of having been granted a permit by the local governing authority and a license by the State of Washington, the named person, firm or organization is hereby authorized to sell Class C Common fireworks at the location designated herein between the hours of 12 noon on June 28th and 12 noon on July 6th, in accordance with RCW 70.77. STRODE , JIM / BAINES , CAL s` Sponsor Loca HWY 3 & HWY 300 - �::Z: jr /s/ ignat a of cial Granting Permit Signature of O 1ci I ng License Title M��/0 i �1(/ yl(' Licensing Division •" lv� �'� OFFICE OF STATE FIRE MARSHAL Agency Olympia, A 98504 Date Permit # Date License #� PERMIT NOT VALID UNLESS SIGNED BY BOTH LOCAL AUTHORITY AND STATE FIRE MARSHAL .�....y..� '.%f�i�. i�.:i��:�i��;�;; •.•//•i•�,,..��\+\\`:;. �.•//r//iM"\i\\\\\.tf:j ,•r1//rrrn.,.\\\\\`.:. '�d1//riln'•,\r\\\�•ra ',r//•/rru...\\.•:`.:••. �i,• �•'i:•/„!.,��:::i�': ••:::�Sr.a::::i,• :.%ir,•.//r/rr•,1�::ii•r �•ii:i:!•yP::�i••:P�: '�''' '�i:;;l•,.��::i••:.�'` ••�::::!.,.�::r•r•�Y�� •..�..••V;�' '%�/Si�•...;t',d;...ii\�' '�/i ii'rir�'�t��'i�•i•�� '%/i iiiilr'�"�Cii�•ii�• ''iii/iiiii;:�t.'�iii�•i\�' ''�i/iiii�r'�^�Cii��i\�' ''�$i//ii�ir��j.`�iC•1/iii%•'',. �.\\�••�•��. .��/////rr,Ilr...,\�\��••\�. .i�•//i/i„":\\\\••O!• !////.ry:";�\\••b. �///.rI .`\\•N\� .i//////r;":`\\•••\�. ✓//.Ir; ,..\•M///r .��. .;�/�ir. •�•:�. 4q��e. ...��. S�igt pp�:�. !�igtt' .`��:. .�,�qtr. ..,��. •.��r,r. a��.t��q�!Y. AUTHORIZATION TO PURCHASE CLASS C COMMON FIREWORKS Possession by the applicant of this completed application, signed by both the local issuing authority and the State Fire Marshal, authorizes the applicant to purchase Class C common fireworks for retail sale from the supplier shown at the location indicated. COPY "A"—Applicant (instructions on reverse side of form) Form SF 601 QX A-252 RETAIL FIREWORKS STAND LICENSEE REQUIREMENTS 1. Fireworks may be sold only in roadside stands or buildings used for no other purpose. 2. A license and permit to operate a fireworks stand does not authorize the sale of articles other than fireworks. 3. Only Class C common fireworks, not otherwise prohibited by RCW 70.7 7, may be sold in fireworks stands. 4. Only fireworks obtained from licensed wholesalers may be sold in licensed retail stands. 5. Fireworks can be sold only between the hours of 12:00 noon, June 28th and 12:00 noon, July 6tb. 6. Fireworks may not be sold between the hours of 11:00 P.M. and 9:00 A.M. 7. At least one adult person (age 18 or over)shall be present at all times the fireworks stand is open to the public. No person under 16 years of age shall be allowed to sell fireworks or remain within a fireworks stand when it is open to the public. 8. Fireworks must be displayed in a manner to prevent handling by the public prior to sale. 9. At least two fire extinguishers, 21/2 gallon water or equivalent, must be accessible to sales personnel. 10. Smoking and the discharge of fireworks shall he prohibited within 25 feet of the fireworks stand. 11. No fireworks shall be discharged within 100 feet of the fireworks stand. 12. "No Smoking" signs, with red letters at least two inches high, shall be posted at conspicuous locations and in plain view of all purchasers. 13. A list of fireworks that may be sold to the public,as furnished by the State Fire Marshal,must be prominently posted at each retail stand. 14. Fireworks stands shall he maintained free from any condition which increases,or may cause an increase of the hazard or menace of fire or explosion,or which may become the cause of any obstruction,delay or hindrance to the prevention,suppression or extinguishment of fire. 15. Adequate and safe means of exit shall be provided from all areas where fireworks are sold. 16. Fireworks stands shall be securely locked when not open for business,or all fireworks removed to a safe location approved by the fire official. 17. Fireworks shall be promptly removed from the fireworks stand and either returned to the supplier or transferred to an approve:'. storage facility, pending ultimate disposal prior to July 31st, at conclusion of the season. 18. Licensees are responsible to instruct all employees in these requirements. 19. Violation of these requirements constitutes a misdemeanor and may cause the immediate closure of the stand and seizure of remainir; fireworks in addition to the criminal penalties of taw. INSTRUCTIONS Applicant. 1. Complete the application,giving the name of the person or firm applying for the license and,if other than the applicant,tale name(f the sponsor under which name the fireworks stand will be licensed and operated. 2. Provide the location of the stand,i.e.the address plus sufficient descriptive information to identify the specific site or structure to be used. 3. Indicate where the fireworks are to be stored prior to sales date,during sales period when stand is closed,and after sales date prier,o July 31st(possession of fireworks by other than licensed wholesalers not permitted after this date). Storage locations are subject to local Fire Dept. approval. 4. Indicate the name of the licensed fireworks wholesaler from whom the fireworks are to be obtained. 5. Fill in the name of the sponsor,or name under which the stand will operate,and the address where the fireworks stand will be located. 6. Sign the completed application and present to the chief fire official of the city, town,county or fire protection district in which the stand is to be located. Fire Official/Local Governing Authority. 1. Make an investigation of the proposed fireworks stand location to determine whether it will be hazardous to property or dangerous to life. 2. Exercise reasonable discretion in evaluating fire and traffic hazards during hours of operation and the safe storage of fireworks before, during and after the sales period. 3. Submit your findings and recommendations to the governing body of the city,town,county or fire protection district for final decision or, in the event that this authority has been delegated to you, approve or deny the permit. 4. If approved, retain Copy B as your record for follow-up inspections and return Copies A and C to the applicant. Applicant. 1. Forward the completed Copies A and C to the State Fire Marshal.Include the$10.00 license fce.The license and completed Copy A will be returned to you,which will authorize the applicant to purchase Class C common fireworks from the licensed wholesaler.License applications must be made to the State Fire Marshal by June 10 of the year for which the license is desired. 2. The Permit must be conspicuously displayed at all times the fireworks stand is open to the public. 3. The storage of fireworks and any requirement/restrictions imposed by the local governing authority must be strictly observed. 4. Unsold fireworks must be returned to the supplier or otherwise disposed of prior to July 31st. Z IW NOTE: The applicant may apply to the State Fire Marshal for a license prior to obtaining local approval.However,the Permit is not valid nor the purchase of fireworks authorized until local approval has been obtained.License fees paid are non-refundable • in the event local approval is denied. Form SF 601 BACK QX A252 DRAYTON INSURANCE BROKERS, INC. 2500 CEATER POINT ROAD POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 FILE COPY BIRMF X (_,OS) LAB MA 35220 TELEPHONE: (205)854-5506 99 CERTIFICATE OF INSURANCE We certify that insurance as outlined below is afforded the Famed Insured under Policy No.A93EG23040 issued by Admiral Insurance Company. NAMED INSURED: Pyrodyne American Corporation Certificate No: 455413 Humdinger Fireworks American Vest Marketing,Inc. Freedom Fire%orks.Inc. American Pyrotechnic Importers.Inc. P. O. Box 1436 Tacoma,R'ashington 98401 PERIOD: November 1, 1993 to October 31, 1994;Both Days Inclusive. COVERAGE: Commercial General Liability including Premises&-Operations Liability and Products 8 Completed Operations Liability. LLMITS OF LI.-kBIL1n•: A) Each Occurrence S1.000,000 b) Products do Completed Operations Aggregate S1,000.000 The above stated limits of liability apply to each occurence but,as respects Products and Completed Operations liability only,in the aggregate. It is certified that in accordance with, and subject to, the terms of the above policy the following SPONSORS AND/OR COM;\4IT7EES A.ND/OR PROPERTY ONNN4 ERS AND/OR LICENSING AUTHORITIES are included as Additional Insured(s), but only in respect of the legal liability of such Additional Insureds for Bodily Injun, and Property Damage arising out of; 1) the ownership or use of the Insured Premises stated below, which are used for the sale of fireworks distributed by the Named Insured, 2) the sale by the Additional Insured of fire%orks distributed by the Named Insured. The limits of liability stated above shall not be increased either; 1)by the inclusion of more than one Insured; nor 2)by the receipt of more than one certificate by an% Insured. WWH-6550 INSUREISI$§S: Location Id: HWY 3 & HWY 300 BELFAIR, WA ADDITIOM*NTY of SON JIM STRODE / CAL BAINES 2497 ALASKA AVE E PORT ORCHARD, WA 98366 their officers,agents,and employees when acting in their official capacities as such. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this certificate may be issued. or mat perarn, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions of such policy. For s pa^ticu;a- concerning such terms,exclusions,and conditions each Additional Insured is referred to the policy documents in the possession of the N":,ed Insured. Should the above described policy be cancelled before the expiration date thereof,the issuing company will mail 30 days' prior u ntten notice to the above named Additional Insured. O1/25/94 DRAYTON INSURANCE BROKERS.INC. DA'E A.J. STRINGER.PRESI =\7 ACUUNT NAME t' Lttj.Lt'yer vireworks - ORDINANCE OF: CHAIRMAN: - BOND AMOUNT: 'TELEPHONE:l ------- ----- ------------- 'TELEPHONE:. SETBACK REOUIRMENTs --------------------------- --------------- STAND 'ADDRESS: _ ---------------------- ---------------------------------- ---------- __________ STAND FACES: ---------------------- SHOPPING CENTER NOTESs TY AND STATE: ---------------------- ---------------------------------- uROSS STREET: -------------- CONTACT/MANAGER STAND SIZE: 24' ---------------------- ----------------------- CONTACT SINGANTURE DATE UP: _ _ ------------------------------------- CREW: -------- — ---- NOTES DATE DOWN: ---------------------------- ------------------------ ------------------------------------- CREW: NORTH �S I 3 — o� i C ST 1ig L i c v , SAY�:•• ,�� ,.�. � �/�T' i s PYRODYNE FILE COPY F22 A M E R I C A N CORPORATION February 1994 REF: WWH-6550 REBECCA S ROGERS CLERK OF THE BOARD MASON COUNTY COURTHOUSE 411 NORTH FIFTH STREET SHLETON, WA 98584 Dear Ms Rogers, Hello, I am Shellie and am doing the Licensing and Insurance for Pyrodyne American Corporation. Please find enclosed with this application all the required documents to apply for a temporary fireworks stand in your county. I have also enclosed a check for $10.00 to cover the permit fee. The following group would like to apply: Jim Strode and Cal Baines 2497 Alaska Ave E Port Orchard, WA 98366 PH (206) 871-3832 Thank you for your assistance. If you require further information or have any questions please feel free to contact me on(206) 922-0800. Sincerely, PY LDE A O ORATION i i hellie A. LEETE Licensing & Insurance Enc. 2523 Pacific Highway East Tacoma, WA 98424 • P.O. Box 1436 • Tacoma, WA 98401 Tacoma (206) 922-0800 • Seattle (206) 838-1099 • FAX (206) 922-2350