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HomeMy WebLinkAboutFIR2013-00015 Fireworks - FIR Application - 5/16/2013 Mason County r Fireworks Permit Application PO BOX 186 426 W Cedar St Permit# FIR 2 p 13 .CY�I 5 Shelton WA 98584 (360) 427-9670 ext 273 Receipt # 5 l;?-O 13--L1 I 1,o RECEIVED CK # Loba3c, MAY 16 2013 Date Received 5 /Lo ,-.16 13 -.?F W rEnAR ST 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: nn Mailing Address: p i City: ACCrYI a St% � -W-A ip: �1'8 Z 1 Contact Number (3taC) ��S (6 1O 9 GYM r Sponsor Informati Name: Mailing Address: -;kq i City: ,-11 State: 1 Zip: Contact Number fy3Cpp) �-7S 1 p EY�E� Washington State Fireworks License Information (Copy Required) License No.: Date of ❑ Pyrotechnic Operator License Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: +6 n i L C, Insured. C Certified Holder: --� ^n �' r Co rm Location of stand/displa Address: 61 h E' Directions to Site: Parcel Number: _ _ c/�o Legal Description: o Legal Property Owner: r F� O 1 b I aC:3?02, * * 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 designated 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 • Desi ated landing area R y V M 0 r .+ o t 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 m intained. Signed Date n FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: • APPLICATION a 3a 1 • a - �t o00 FOR RETAIL FIREWORKS STAND PERMIT WWM6505 TO: Governing body of city,town, or county in which DATE OF 03.12.13 fireworks stand will be located. I APPLICATION: Applicant Name: Address, City,State: NORTH MASON PEE WEES 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Sponsor(If other than applicant): Address, City,State: BRETT BERGDAHL 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Location of proposed fireworks stand: [Enclose drawing of stand location] a o i n E- 5+c�--R o 6+ E 300 QFC BELFAIR, WA Manner and place of storage prior,during, and after sales dates: ON SITE WITH SECURITY State Licensed Fireworks Supplier: American Promotional Events NW 2120 Milwaukee Way, Tacoma, WA 98421 - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FIREWORKS STAND PERMIT For The Fireworks Sales Year Of: 2013 (Must be conspicuously displayed at all times while the stand is open to the public) By virtue of having been granted a license by the State of Washington and this permit from MASON COUNTY the local governing authority, the named person, firm or organization is hereby authorized to sell U.N. 0336 I AG Consumer fireworks at the location designated herein between the following date and times: Sales For July 4& Sales For December 31" From: From: To: To: Sponsor: NORTH MASON PEE WEES Location: OFC NE 1403 OLD BELFAIR HWY BELFAIR,WA /s/ /s/ FOR BRETT BERGDAHL Signature of Official Granting Permit Signature of Applicant Title: Agency: Date: Permit Number: Licensee Name: NORTH MASON PEE WEES License Number: 00506 3000-420-013(Rev.2105) (�� //U Q Q 20 i 3 . 00o 15 J /w' Q Y V I CONCEPTUAL SITE PLAN a W Q Z - FC \ Q.w A"c CRJ O I STORE#101 .. T-W i �/ '.� tY 4 9ELFAIR Z U) O � Q"�•'�./'.�CJ�\� saps \ < Z a + ' S RE86iYE AF�A \ � O .> 1Ti ��• 4or ���C T1 UDeMllM.00*=-l=M IQ 2 DAAMEM \ a.- VICINITY MAP Cc— h�C _ re.1Cal f-c N \ eG�l�NafNN[M�4 \\ RLf m�iiaxauna „' aaa6YYgoMnplaN[tKNaNlta/ QFC GAS STATION ADDITION 45.05 SF. =DeIr:AIRHIGMAr ANDNORM SNORE ROAD attar � BUSIM(3VLDWO \ `\ 1 � . .ee G a w�[ Ilt�1D r� NOBS 4 N.waWwu[at[NAN a![RD an NouNUN Na w,w NI'lYda�l!a6[! OLD BELFNti HCiFiWAY °"" a. a - - - - - - - SITE PLAN �. Zo IS A4C" CERTIFICATE OF LIABILITY INSURANCE DATE 11/1/2013 3/19/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER Lockton Companies,LLC NAME: 3280 Peachtree Road NE,Suite 800 PHONE FAX A/C No Ext: , No): Atlanta GA 30305 E-MAIL (404)460-3600 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Scottsdale Insurance Company 41297 INSURED American Promotional Events,Inc. INSURER B: 1359629 DBA TNT Fireworks,Inc. INSURER C: P.O.Box 1318 INSURER D: 4511 Helton Drive INSURER E Florence AL 35630 INSURER F COVERA991VI6101 CERTIFICATE NUMBER: 12253602 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DDIYYYY MMIDD/YVYY A GENERAL LIABILITY Y N CPS1612503 II/l/2012 11/1/2013 EACH OCCURRENCE DAMAGE TO RENTED X MMERCIAL GENERA ABILITY PREMISES(Ea occurrence) $ 100 000 CLAIMS-MADE XX OCCUR MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- $ JECT X LOC AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE= (Ea accident) $ XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX ALL OWNED SCHEDULED BODILY INJURY Per accident $ XXXXXXX AUTOS AUTOS $ XXXXXXX NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ XXXXXXX UMBRELLA UAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAB HCLAIMS-MADE AGGREGATE $ XXXXXXX DED I RETENI I $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ XXXXXXX OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ XXXXXXX If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ XXXXXXX DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER APPLICABLE TO THE CARRIERS LISTED AND THE POLICY TERM(S)REFERENCED located at QFC,NE 1403 Old Belfair HWY,Belfaire,WA(WWM6505)Certificate holder is an additional insured on the General Liability as required by written contract subject to policy terms,conditions,and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 12253602 AUTHORIZED REPRESENTATIVE Mason County North Mason Pee Wees PO Box 186 426 W Cedar Shelton WA 98584 �� r ACORD 25(2010I05) The ACORD name and logo are registered marks of ACORD © 9$8- 10 CORD CORP TION.All rights reserved TI Z ' N CONCRETE MECHANICAL MANUFACTURED HOME 0 O Bak- By X � Footings !Setbacks Gas Piping Ribbons = OInterior Date By interior-Date By Date By � 00 Exterior Date By Exterior-Date_ By Set-upC/� INSULATION O Point Load/isolated Footings Date By O BG 1 SLAB INSULATION -- -- -n Z Date By Data By FIRE DEPARTMENT Foundation Walls Floors Date By m _ M Date By Date By DECKS FRAMING Walls Date By m Date By Data By PROPANE TANKS Cl) PLUMBING vault Date By .___,_ Date By OTHER Groundwork Attic Date lay Type- Date B y Date B v D.W.v DRYWALL Type Int.Brace Wall pate Dy X M Date By Date By ...---_.---- FINAL INSPECTION N to O M Water Line Fire Separation � Date By Date By Date By Ca o o Pass or Request Inspect. o Type of Insp. Fail Date Date Done By Comments U, m m cc y M O n O 3 a 0 N O S U) �D N (l] rD O 0)