HomeMy WebLinkAboutFIR2010-00016 Final Fire Works Stand - FIR Permit / Conditions - 6/28/2010 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 FIR2010-00016
APPLICANT: MIKE ALLEN RECEIVED: 6/1/2010
CONTRACTOR: PHANTOM FIREWORKS 360.253.396.0966 LICENSE: WSPEFL-01908 EXP: ISSUED: 6/15/2010
SITE ADDRESS: 141 NE CLIFTON LN BELFAIR EXPIRES: 12/15/2010
PARCEL NUMBER: 123294190023
LEGAL DESCRIPTION: TR 2-13 OF NE SE LOT: 3 OF SP#2929
PROJECT DESCRIPTION: FIRE WORKS STAND-BELFAIR CENTER
GENERAL INFORMAT10N System Information
Type of Use: STND Sprinkler Heads: Audible Switches: Pull Stations:
Fire District: 2
Hood&Duct?: N Flow Switches: Visual Devices: Door Releases:
Pressure Switches:: Smoke Detectors: Duct Detectors:
Dry Chemical?: N Zones: Heat Detectors:
Wet Chemical?: N
Sprinkler?: N
Standpipe?: N SQUARE FOOTAGE FEES
Monitoring Company: First Floor:
Type Amount Due Amount Paid
Monitoring Phone No.:() - Second Floor: Fireworks Stand Permit $100.00 $100.00
Auto Fire Alarm?:N Third Floor;:
Total: $100.00 $100.00
FIR2010-00016 Please refer to the following pages for conditions of this permit 1 of 6
1.) Owner t is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
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2.) valid P Wust be on-site.
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FIR2010-OOD16 Pka54T IIft fotlowim Pages for oonctiitions of this partnit. ', 3 'of
3.) Consumer fire works may be sold only on the following days and times.
June 28th from 12 noon to 11 PM
June 29th to July 51h from 9 Ah4 to 11 PM
July
!y 6t2m 9 AM to 12 noon
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A fire works stand shall not be located more than 150 feet from an approved access road. Shall be at least 100 feet from another fire works stand or
separated by a road,street or highway at least 30 feet in width. Shall not be located any closer than allowed by the attached table to other structures or
exposures or be located closer than 100 feet from any flammable Ilquid or ges dispensing device,or 300 feet from any flammable liquid or gas bulk
CI) stora or dispensing facility.
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The minimum areas around a fire works stand,as specified in the attached table,shall be kept free from dry grass,brush,or combustible debris.This
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Motor
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Fireworks shall not be discharged wilhln 300 feet of any fireworks stand.A sign stating"No Fireworks discharge within 300 feet"in letters at least 2 inches
hi
gh and trasting color shall be posted conspicuously on all sides of the structure.
' No smoking shall be allowed within the fireworks stand or flagged off area.Signs stating"No Smoking WItin 100 feet"in letters at least 2 inches high and
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X contra icolors shalt be posted conspicuosly on all sides of the structure.
All battery powered equipment, electrical equipement and cords shall be UL listed and used in accordance with that listing. Extension cords shalt be of an
industrial arade type and shall be protected from physical damage.
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° >_ All heating devices shall be UL listed.Only heating devices with sealed type elements shall be used, i,e- oil filled or water filled radiator type.Open flame
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or openele, een h atingdevices areprvhl5ttetl."
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Generators shall be located a minimum of 20 feet from any fire works stand. Fuel storage is limited to 5 gallons.
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A minimum 1A Inch wife Isle siidll be niainiained inside the full iengii t of the siarid.
v Customers are not allowed inside the fireworks stand.There shall be a minimum of 2 exits at least 28 inches in width located at oppslte ends of the stand.
These ex ��remain unlocked and unobstructed durng hours of operation or when stand is occupied.
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Sleeping SJ e a fireworks stand is prohibited.
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FIR2010.00016 Fie'ase refer to the following pages for wriditions of thla permit of 6
The location of the nearest phone shall be posted in the fireworks stand.All occupants of the stand shall be informed as to the location of this phone.The
` local eme�enc�phone number,911,and the address of the fireworks stand shall be conspicuously posted Inside the stand.
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There shal a minimm u of 2 approved 2 112 gallon pressurized water fire extinguishers located adjacent to each exit door.
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Cooking.o n flame or any type of open flame equipment is prohibited in a fireworks stand,
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Fireworks stands shall be locked when unoccupied and not open for business if fireworks are storged In the stand during these times. Fireworks stand
shall not be locked when occupied.Fireworks maybe removed or transferred to a temporary storage structure or location approved as part of the license
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Fireworks may be stored in a locked and secured retail fireworks stand,truck,container or trailer that is at least 20 feet from the fireworks stand during
business hours, or in a locked and secured metal or wooden garage,shed, bam or other accessary building that Is at least 20 feet from the fireworks
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' At least one person 18 yrs of age or older shall be on duty in the fireworks stand when fireworks are being sold to the public.Such person shall be
responsible for the supervision of the fireworks stand and its operation.No person under the age of 16 shall be allowed to occupy the fireworks stand
when ape t the public.
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It is illegal to knowingly sell fireworks to persons under the age of 16.A sign slating"No Sales Of Fireworks to Persons Under the age of 16"in letters at
least 2 inches high and in contrasting color shall be posted on the front of the stand.A photo ID is required and it is responsibfity of the seller to require
proof of a river's license or photo ID showing date of birth issued by a public or private school,state,federal or foreign government is acceptable,
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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 Ina progress inspection withln the 180 day period. Final inspection must be approved before building can be
c occupied. Proof of continuation of work is by means of a progress inspection.The owner or the agent on the owners behalf,represents that the Information provided is Bccurale
0 o and grants employees of Mason County access to the abnve des Il:)ed property and structure
--for review and inspection.
-OWNER ORAGENT` tGLV J- -• --DATE -1t7— - {• -- .. �. - -� - - - - -
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FIR2010-00M Please dqr following to," pagea for conditions of this permit. 5 of 6
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CONCRETE MECHANICAL MANUFACTURED HOME r
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L Footings f Sff� Gas Piping
t Date By Ribbons Z
CInterior Date By Interior-Date By bate By
O Exterior Date By Exterior-Date B Sat-up
INSULATION m
p� point Load!Isolated Footings Date 8y
BG f SLAB INSULATION
Date By Data By FIRE DEPARTMENT
Foundation Walls Floors Date By
Date By Data By DECKS
FRAMING Watts Date By
Date By Date By PROPANE TANKS
PLUMBING Vault Dote By
Date lay OTHER
Groundwork Attic
Date By Date By Type:
bate By
D.w.v DRYWALL Type
Int.Brace Wall
Date By ate By a
D 6y
FINAL.INSPECTION
N Water Line Fire Separation O
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Date By Date By Date By O
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Pass or Request Inspect. CD
Type of Insp. Fail Date Date Done By Comments
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FIRE & LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTION
FACILITY Z ADDRESS CITY ZIP PHONE
_ NAME
INSPECTOR0.� AGENCY DA E
DAVE 360-427-9670 X-273 MASON COUNTY FIRE MARSHAL FD''L !o /�°
ITEM STATEMENT OF CODE OR WAC CORRECTIVE ACTION CORRECTION
NO. DEFICIENCY REFERENCE REQUIRED REQUIRED BY
DATE
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THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN SIGNATURE REINSPECTION DATE
EXPLAINED TO ME,AND I AGREE TO MAKE CORRECTIONS ;
NO LATER THAN THE DATES INDICATED
PAGE _OF PAGES
White Copy: Occupant— Yellow Copy: Fire Marshal—Pink Copy: Fire District
04/30/2010 08:07 3606745892 Sh.HS MAIN OFFICE PAGE , 10/11
1► Mason County
M Man" Fireworks Permit Application
P.O_ BOX 186 Permit# FIR �o
426 W Cedar St �1L
Shelton WA 98584 Receipt #
(360) 427-9670 ext 273
Date Received — i ^ ' Q
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 Tnformatio
Name:
Mailing Address:
City: State; Zip. _J�3(0
Contact Number
Sponsor nformation
Name:
Mailing Address: 1
Contact Number
ty: State: Zip:
Washington State Fireworks License Information (Copy Required)
License No.: ( Date of
J1 t.L Issue:
Pyrotechnic Operator License Fireworks Stand License
Bond or Certificate of Insurance
(copy of Certificate/ Bond Required)
Provider:
Insured:
Certified Holder:
I
Location of stan /dis la
Address:
Direction to Site:
Parcel Number: 12
Legal Description:
Legal Property Owner:
Please seethe reverse side to complete your application
3 0
04/36/2010 08:07 3608745892 SKHS MAIN OFFICE PAGE • 11/11
The following eminent information MUST be provided on site diagram below
Locations and Setback distances from the back, sides and front of retail sales or
desi ated display areas to:
• Fire Hydrants • Property Lines
• Buildings • Parking
• Combustibles • Public Roads and Right of Ways
• I✓ire Lanes • Private Roads and Right of Ways
• Trees/Brush . Landmarks
• Utilities and Gas • Mortar separation distance
• I7esi Hated landin area
FApplicants Affidavit
rtify that the information provided herein is accurate and that compliance with
ounty, State n ederal laws pertaining to the sales or dischar a of fireworks
shall be mai i d.
Signed Date 2
FOR OFFICIAL IJSE BELOW THIS LINE
Accepted By: Date
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MASON COUNTY FIRE MARSHAL
PIIII Mason County Bldg.III 426 W Cedar St
PO BOX 186 Shelton,WA 98584
g (360)427-9670 Ext.273
CODE ENFORCEMENT FIRE INSPECTIONS FIRE INVESTIGATION PUBLIC EDUCATION
STANDARDS FOR THE OPERATION OF RETAIL FIREWORKS STANDS
Sales
Consumer fire works may be sold only on the following days and times.
• June 28"' from 12 noon to 11PM
• June 29`h—July 5th from 9AM to 11PM
• July 6�h from 9AM to 12 noon
• December 27th—31"from 12 noon to II PM
Approved Fireworks
Only Washington State Fire Marshal approved Class C common fireworks may be sold.
Fireworks Stand Location
• A fireworks stand shall not be located more than 150' from an approved access road,
• Shall be at least 100' from another fireworks stand or separated by a road, street or highway at least
30' in width,
• Shall not be located any closer than allowed by the table below to other structures or exposures,
• Or be located closer than 100' from any flammable liquid or gas dispensing device, or 300' from any
flammable liquid or gas bulk storage or dispensing facility.
Retail Fireworks Stands—Minimum Clearances
Buildings Combustibles Property Line Parking Motor Vehicle Motor Vehicle
Traffic, Traffic,
Public Road Private Way
Back of Stand 20' 20' 5 20' 20' 5'
Side of Stand 20' 20' 5' 20' 20' 5'
Front of Stand 20' 20' 20' 20' 20' 20'
Surrounding Area around Fireworks Stands
• The minimum areas around fireworks stands, as specified above, shall be kept free from dry grass,
brush or combustible debris. This area shall be marked and flagged.
• Motor vehicles or trailers may not be parked within 20' of the fireworks stand except when
delivering, loading or unloading fireworks.
• Fireworks shall not be discharged within 300' of any fireworks stand. A sign stating No Fireworks
Discharge Within 300' in letters at least 2"high and in contrasting color shall be posted
conspicuously on all sides of the structure.
• No smoking shall be allowed within the fireworks stand or flagged off area. Signs stating No
Smoking Within 100' in letters at least 2"high and in contrasting color shall be posted
conspicuously on all sides of the structure.
Electrical Supply & Usage
• All battery powered equipment, electrical equipment and cords shall be UL listed and used in
accordance with that listing. Extension cords shall be of an industrial grade type and shall be
protected from physical damage.
• All heating devices shall be UL listed. Only heating devices with sealed-type elements shall be
used, i.e. oil filled or water-filled radiator type. Open flame or open element heating devices are
prohibited.
• Generators shall be located a minimum of 20' from any fireworks stand. Fuel storage is limited to 5
gallons.
Fireworks Stand Operations
• A minimum 24"wide isle shall be maintained inside the full length of the stand.
• Customers are not allowed inside the fireworks stand.
• There shall be a minimum of 2 exits at least 28"in width located at opposite ends of the stand.
These exits shall remain unlocked and unobstructed during hours of operation or when stand is
occupied.
• Sleeping inside a fireworks stand is prohibited.
• The location of the nearest phone shall be posted in the fireworks stand. All occupants of the stand
shall be informed as to the location of this phone.
• The local emergency phone number, 911,and the address of the fireworks stand shall be
conspicuously posted inside the stand.
• There shall be a minimum of 2 (two) approved 2 1/2 gallon pressurized water fire extinguishers
located adjacent to each exit door.
• Cooking, open flame or any type of open flame equipment is prohibited in a fireworks stand.
• Fireworks stands shall be locked when unoccupied and not open for business if fireworks are stored
in the stand during these times. Fireworks stands shall not be locked when occupied. Fireworks
may be removed or transferred to a temporary storage structure or location approved as part of the
license and permit.
• Fireworks may be stored in a locked and secured retail fireworks stand, truck, container, or trailer
that is at least 20' from the fireworks stand during business hours, or in a locked or secured metal or
wooden garage, shed,barn or other accessory building that is a least 20' from the fireworks stand.
• At least one person 18yrs of age or older shall be on duty in the fireworks stand when fireworks are
being sold to the public. Such person shall be responsible for the supervision of the fireworks stand
and its operation. No person under the age of 16 shall be allowed to occupy the fireworks stand
when it is open to the public.
• It is illegal to knowingly sell fireworks to persons under the age of 16. A sign stating"No Sale Of
Fireworks to Persons Under the Age Of 16"in letters at least 2"high and in contrasting color shall
be posted on the front of the stand. A photo ID is required and it is the responsibility of the seller to
require proof of age. Driver's License or Photo ID showing a date of birth issued by a public or
private school, state, federal or foreign government is acceptable.
04/30/2010 08:07 3608745892 SKHS MAIN OFFICE PAGE - 08/11'
FIRE PROTECTION BUREAU
FIREWORKS LICENSING PROGRAM
PO Box 42600 X N I��i01-k
Olympia WA 98504-2600 UM
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'`".°,"°`� (360)596-3914 FAX: (360)596-3934
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT
TO DATE OF
A.PPLICA.TION
Applicant Name Address,City,State
H I kp A 1 711 It FawcetNe, S�,108 Ta 1,,k
Sponsor(if other than applicant) Address,City,State
Location of;r9i3osed fireworks stand [Enclose drawing of stand location]
NE Cl L.ut ICE &v Goad R�. WA 9852&
Manner and place of storage prior,during, and after sales dates
State-Licensed Fireworks Supplier
.10 Rp Alm , Pha6inm Eje"a&-cs
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FIREWOR\KS STAND PERMIT
For the Fireworks Sales Year of:
(Must be conspicuously displayed at all times while the stand is open to the public)
Tay virtue of having een granted a license by the State of Washington and this permit from
mcu�oh as the local governing authority, the named person, firm or
organization is hereby(authorized to sell U.N. 0336 1AG Consumer fireworks at the location
designated herein between the following date and times:
Sales for July 4"' Sales for December 31 st
From: TEE -141L /�l�(� from:
To: j.t�V _2 10 To:
Sponsor—SOLI- TlrI tG
Location
Signature of Official Granting Permit Sig rc o pp scant
Title Agency
Date Permit Number
Licensee Name License Number
RETAIL FIREWORKS STAND PLOT PLAN N
Fireworks Product Wholesaler: Phantom Fireworks - (253)396-0966 Fax (253)396.0771 1111 Fawcett Ave Ste 108., Tacoma, WA 98402
Stand Location: Belfair Center Vacant Lot Organization Name: S. Kitsap Vocal Music Emergency Contacts: Holly Nay
Boosters
Stand Address: N.E. Clifton Lane&N.E. Roy Boad Contact Person: Mike Allen Account Manager: Holly Nay
Road
Stand City: Belfair,,WA 98528 Contact Phone: Phone: 253.380.5937 cell
Stand Size: 20x40 Account Number: Tacoma Office: 253.396-0966
Set Date: 06/26/10 PLEASE CONTACT ACCOUNT MANAGER Office Manager: Shelby Crumley
Removal Date: 07/07/10 WITH ANY QUESTIONS Phone: 253.396.0966 office
Roy Boad -
- , Road
Parking Area
150 -�
711111
"-25'� 65
25'
Notes: Blue box signifies
20'X40' tent. Dash lines eriyaki
Wo
notates setback separation
roped off with traffic stan-
chions and pennants. /
Highway 3
20x40 Tent
Banner Placement
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BANNER#9 BANNER#3 = '
BANNER#1
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Z Z tcr, #9Table Display #10 Table Display #11 Table Display #12 Table Display w
BANNER#2
2.5'aisle iv
6' exir #8 Table Display #7 Table Display #6 Table Display #5 Table Display EXIT 6'
2.5'aisle
BANNER#2 #4 Table Display #3 Table Display #2 Table Display #1 Table Display Z A
3'
LTO
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3'
BANNER#1
FIREWORKS
PHANTOM
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BANNER#5
BANNER#3
Extinguishers Register EXiT'Exit Signs above all exits
Fireworks will be displayed on 8'and 6'"banquet tables"with backup stock in original cases,beneath the tables,hidden from public by skirting. *All exits 5'to 6'wide
Fireworks on display will not have exposed fuses. If an item has exposed fusing that item will not be within reach of customers. *Location of nearest phone at registers
Pallet displays will consist of original cases stacked with fireworks displayed on top of cases. *3'distance from sidewall to product
Fireworks in original cases are packed"box within a box",boxes and labeled CFR 49 compliant. *2.5'Aisle minimum
FROM FAX NO. Oct. 16 2009 12:56PM P2
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JUNE 5 20QI
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Gentlemen:
We hereby certify that 183 YOS VINYL CLEAR 54" . 019
FP,-CFM INTERLEAF 972041
1
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(Part Number)
shipped on (5/a t Invoice Na._ 17 3 216 33
(Dare)
against your purchaso order number KEN 7601 , comply wide
sTCC4,cakioas CALIFORNIA FIRE MARSHAL REG. F-209.
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The A,strup Company
J N BOTZMAN
City of G1evdand
County of Cuyahoga
State of Ohio
Subscribed and sworn to before mc,a Notay Public
6Th1 day of JUNE 20 01
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Phantom Fireworks
Pacific Northwest Division
2367 Lincoln Ave Tacoma, WA 98421
PH (253) 380-5937 FAX (253) 396-0771
FIREWORKS STAND AND LEASE AGREEMENT
This agreement is made between Belfair Center LLC as the Lessor,and Phantom Fireworks,as Lessee,for
the purpose of allowing the sale of Consumer Fireworks located at: 1
NAME: Belfair Center ADDRESS: SE Roy Boad Rd and Clifton Ln (Sec;jYW b��
ORDINANCE: Mason County CITY/STATE: Belfair,WA
The parking lot or commonly occupied premises as listed above is owned and/or controlled by the Lessor, and
the Lessor grants to Lessee, and the group selected by the Lessee,the exclusive right to operate a Fireworks
Stand on these premises for the period from:
Date and Year Date and Year Rental Fee Initial
From: June 20,2010* To: July 10, 2010* $ 1,200.00 and 10%of sales
-
exceeding$12,000.00
From: June 20, 2011* To: July 10,2011* $ 1,200.00 and 10%of sales
exceeding$12,000.00
From: June 20, 2012* To: July 10, 2012* $ 1,200.00 and 10%of sales
exceeding$12,000.00 q'
*The stand/tent may be dropped and erected a week before and taken down a week after
The Lessee agrees to the following Terms and Conditions:
1. Lessee will provide liability insurance coverage and post with Lessor,prior to occupancy,a certificate of insurance,evidencing
the insurance in force covering the erection,maintenance and operation of the fireworks stand. The insurance shall name the Lessor
as an additional insured,and Lessee will hold the Lessor harmless from any claims arising from the maintenance or operation of the
stand. Insurance coverage will be in the amount of$10,000,000(TEN MILLION DOLLARS).
2. Lessee shall pay all cost involved in erection,maintenance and operation of the stand,and,on departure:the Lessee shall return
the premises to its original condition.
3. Lessee shall obtain and pay for all necessary permits and licenses required by law,shall post with local authority and debris or
performance bonds,which might be required;and shall adhere to all laws and regulations.
4. If the sale of fireworks is prohibited by public authority,or if Lessee is unable to secure a group to operate on the property and the
property is not utilized,the lease amount prepaid will be refunded,and this lease agreement shall automatically become null and
void. If the local municipality having jurisdiction over this stand limits the sale of fireworks or makes any other local rules
modifying the state statues,s,then lease agreement is subject to revision. �Pv
ow
5. If the property is soldlor is otherw�ise inaccessible due.to construction or the like,then this lease is subject to rev;sion.d/'a4seeuq�
6. Lessee shall pay in full to Lessor,the rental fee specified above for each year.
7. If Lessee is in compliance with this lease,Lessee shall have the right to renew this lease for the next annual fireworks season on
the same terms.
THIS AGREEMENT IS CONTINGENT UPON LESSEE SECURING LOCAL AND STATE LICENSES.
LESSOR: Ted Tollefson AGREED AND DATED: l Z. Z,01 d
SIGNATURE: .� TITLE: Pr-v N6
ADDL INSURED: "i'��,� �R4�Can m e Nct a.! fib >rk ,Q a & 6
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LESSEE: Phantom Fireworks—David Witte(Regional Manager) SIGNATURE:
LESSOR MAILING ADDRESS: 16650 NE 79"St.,Ste. 103 TELEPHONE:
CITY,STATE,&ZIP code: Redmond,WA 98052
TAX IDWSOCIAL SECURITY: 9 1-,15801 1+,S CORP: INDIVIDUAL OR PARTNERSHIP:
BELFAIR VALLEY PLAZA
A PORTION OF SECTION 29. TOWNSHIP 23 NORTH. RANGE 1 WEST. W1•L
MASON COMITY. WA50GTON
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CERTIFICATE OF INSURANCE ISSUE DATE
ACORDTM 03/05/2010
PRODUCER This certificate is issued as a matter of information only and confers no rights
MCGRIFF,SEIBELS&WILLIAMS,INC. upon the Certificate Holder. This Certificate does not amend,extend or alter the
P.O.Box 10265 coverage afforded by the policies below.
Birmingham,AL 35202
800-476-2211 COMPANIES AFFORDING COVERAGE
ComApany Liberty Surplus Insurance Company
INSURED Company Ironshore Specialty Ins.Co.
B J Alan Company B
Big Bear Fireworks,Inc.
Phantom Fireworks, Inc. Company
555 Martin Luther King,Jr.Blvd C ,,,,
Youngstown,OH 44502 !F�
Company "
;tip ,_•
Company
E
This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding
any requirement,term or condition of 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 subject to all the terms,conditions and exclusions of such policies. Limits shown may have been reduced by paid claims.
CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE LIMITS OF LIABILITY
LT EXPIRATION
A GENERAL LIABILITY EGLB0188893019 10/30/2009 EACH OCCURRENCE $ 1,000,000
®Commercial General Liability 10/30/2010 FIRE DAMAGE $ 100,000
❑Claims Made ICI Occurrence
❑Owners'and Contractors'Protection MEDICAL EXPENSE $ 10,000
❑ PERS.AND ADVERTISING INJURY $ 1,000,000
❑ GENERAL AGGREGATE $ 2,000,000
General Aggregate Limit applies per: PRODUCTS AND COMP.OPER.AGG. $ 2,000,000
❑Policy ❑Project ®Location
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
❑Any Automobile BODILY INJURY Per erson $
El All Owned Automobiles
❑Scheduled Automobiles BODILY INJURY Per accident $
Cl Hired Automobiles PROPERTY DAMAGE Per accident $
❑Non-owned Automobiles COMPREHENSIVE
❑ COLLISION
WORKERS'COMPENSATION WC Statutory Limit Other
AND EMPLOYERS'LIABILITY EL EACH ACCIDENT $
EL DISEASE Each employee) $
EL DISEASE(Policy Limit $
B EXCESS LIABILITY 01FNC0906001 10/30/2009 EACH OCCURRENCE $ 9,000,000
®occurrence ❑Claims Made 10/30/2010 AGGREGATE Is 9,000,000
$
$
Location:SE Corner of Roy Boad Road and Clifton Lane,Pad#3,Belfair WA 98528.
Dates of operation:June 26th thru July 10th 2010.
Mason County,it's agents,employees,volunteers and/or officials while acting in their official capacity.
The above listed are Additional Insured respects to General Liability policy as required by written contract subject to policy terms,conditions and exclusions.
CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Belfair Center, LLC
Ted Tollefson Authorized Representative
16650 NE 79th Steet
Ste.103
Redmond,WA 98052 �c2G �.. .�s•�_.(Z
Page 1 of 1 Certificate ID p LPBXEVZY
B.J. ALAN COMPANY NW
PHANTOM FIREWORKS
1111 Fawcett Ave., Ste. 108 - Tacoma, WA 98402
March 30, 2010
PHANTOM NIGHT SECURITY
Tents are equipped with sidewalls and lighting. The tent will be attended
24 hours a day and will be lit and look attended at night when the tent is
not open for sales.
Nighttime, off-hours attendant(s) will be providing security during hours
the tent is not open for sales. Nighttime attendant(s) will have
telephone(s) in case of emergency. Nighttime attendants will be
instructed to call 911 for emergencies and they will be given emergency
numbers to contact B.J. Alan Company NW/Phantom Fireworks
management.
There will be a trailer, camper, or other vehicle on site during closed
hours to confirm someone is on site at the tent. Trailer, camper, or other
vehicle will be in close proximity to the tent, per local codes and rule's
allowable setbacks.
Nighttime attendants will carry whistles, horns, or other noisemaking
devices to alert any intruders to their discovery.
All information regarding the sale of fireworks and nighttime watch over
the fireworks will be covered at Fireworks Retail Orientation Workshops,
mandatory attendance with every group associated with the sale of
Phantom Fireworks.
Phone: 253.396.0966 Fax: 253.396.0771
__ I
IWashington State Patrol 11595
Fire Protection Bureau Fireworks Stand License
Office Of The State Fire Marshal
Washington State Fireworks License License is Non-Transferable and Valid for Only One Stand
Licensee Information
South Kitsap Vocal Music Boosters -
1111 Fawcett Avenue, Suite 108 State Fire Marshal Signature
Tacoma, WA 98402 License Number: WSPFL 01908 Detach this wallet card and carry with you for
verification of certification.
i
Stand Information Washington State Patrol 1 1 5 9 5
Fire Protection Bureau
Contact Person: Mike Allen Office Of The State Fire Marshal
Phone Number: (253) 396-0966 ANNUAL FIREWORKS STAND LICENSE
County: Mason Date of Expiration Date of Issue Licensee: South Kitsap vocal Music Boosters
January 31, 2011 May 6, 2010 Contact Person: Mike Allen
Stand Number: SN-05272 1S' License Number: WSPFL-01908
Stand Number: SN-05272 [Valid For One Stand]
Date of Expiratio puar 31, *Ietj',d
(� Zg
Q Location: b o
Stand Location' Q [Stand oc lion
To Be C y Licensee]
I [Stand Location T�BeCo �pletedBy Licensee]
State Fire Marshal Signature Licensee Signature
3000-420-012 (R 9/05)
I
«4/30/2010 08:07 3608745892 SKHS MAIN OFFICE PAGE .07/11'
FIRE PROTECTION BUREAU
�ypa owp,, FIREWORKS LICENSING PROGRAM.
PO Box 42600
Olympia WA 98504-2600 `
(360)596-3914 FAX: (360)596-3934
A.PPLICA.TION FOR RETAIL, FIREWORKS LICENSE
Instructions:
Please complete this application and mail to the address noted above with a
$40 check or money order(non-refundable)payable to the Washington State
Patrol.
.
DO NOT SEND CASH
Cot
This application must be received by the Washington State Patrol Fire Protection Bureau NO LATER
THAN MAY 11 for annual sales commencing on both June 28 and on December 27 of the year of
issue. Applications for sales commencing only on December 27 of the year, of issue can be received no
later than November 1. There are absolutely NO exceptions. This apnfication must be signed, and
only completed a lications will be -ic-cepied. This license is NON-TRANSFERABLE.
Per RCW 70.77.320, "If application is made by a partnership, it shall be signed by each partner of the
partnership, and if application is made by a corporation,it shall be signed by an officer of the
corporation,and bear the seal of the corporation."
Name of Applicant or Organization Licensee Contact Phone Number
*W VOW HO&Q, &04eks- A _
Mailing Address (Please note the license will be mailed to this address)
l l I Fa w cett. A\P, ,2& I(11 IL-51
Cit State I Zip Code County Location. of Fireworks Stand
Tacorv(a. 'WA b9 n
Contact Person Marne Address, and Phone Number if Different Than Licensee
Address of
Temporary Storage
)Facility
This application is hereby made for a Retail Fireworks License. This license authorizes the licensee to
purchase consumer fireworks, legal in the state of Washington, for retail sale. In.making this
application., I agree to abide by all requirements of the State Fireworks La-%7,, (RCW 70.77) and the rules
and regulations of the Washington State Fire Marshal's ffce(WAC 212-17), and all local ordinances
for fireworks in the county/city/jurisdiction. 1.will oiler e myWtand.
Date o Sig aturc
s��
PHANTOM
Forewo r s c o m
B.J. ALAN COMPANY NW / PHANTOM FIREWORKS - 1111 Fawcett Ave. Ste 108, Tacoma, Washington 98402
Mason County
Fireworks Permit Application
Enclosed is an application for Fireworks Stand permit for the 2010 season.
Stand Location: 141 N Clifton Ln. Belfair, WA 98528
Group Name: South Kitsap Vocal Music Boosters
Contact Person: Mike Allen
Address: 425 Mitchell Ave. Port Orchard, WA 98366
Mailing Address: 1111 Fawcett Ave. Ste 108 Tacoma, WA 98402
Phone: (360) 769-8693
Whsl. Supplier: Big Bear Fireworks Inc/ Phantom Fireworks
State License #: 11595
Individual completing Application Packet:
Name: Holly Nay Phone: (253) 396 - 0966
Requirements
Item Amount Check # Check Box
State License Jcopy of state license $40.00 Yes ® No ❑
Fireworks Permit $100.00 Yes ® No ❑
Fireworks Permit Application Yes ® No ❑
Site Plan Yes ® No ❑
Tent Plan / Stand Plan Yes ® No ❑
Certificate of Insurance Yes ® No ❑
Certificate of Flame Resistance Yes ® No ❑
Property owner'spermission/ copy of lease agreement Yes ® No ❑
State Patrol Application Yes ® No ❑
Night Security Yes ® No ❑
Yes ❑ No ❑
Phone: 253.396.0966 Fax: 253.396.0771