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Home My WebLink AboutFIR2005-00020 FinalFireworks Stand - FIR Permit / Conditions - 6/28/2005 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 FIR2005-00020 APPLICANT: ANDREA KOZAK RECEIVED: 5/24/2005 CONTRACTOR: LICENSE: EXP: ISSUED: 6/27/2005 SITE ADDRESS: 141 NE CLIFTON LN BELFAIR EXPIRES: 12/27/2005 PARCEL NUMBER: 12329419002'2- LEGAL DESCRIPTION: TR 2-13 OF NE SE LOT: 2 OF SP#2929 PROJECT DESCRIPTION: Fireworks Stand GENERAL INFORMATION System Information Type of Use: STND Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 2 - Flow Switches: Visual Devices: Door Releases: Hood& Duct?: Pressure Switches:: Smoke Detectors: Duct Detectors: Dry Chemical?: Zones: Heat Detectors: Wet Chemical?: Sprinkler?: Standpipe?: SQUARE FOOTAGE FEES Monitoring Company: First Floor: Type Amount Due Amount Paid Monitoring Phone No.:0- Second Floor: Auto Fire Alarm?: Third Floor;: Fireworks Stand Permit $100.00 $100.00 Total: $100.00 $100.00 FIR2005-00020 Please refer to the following pages for conditions of this permit. 1 of 3 CASE NOTES FIR2005-00020 • ' CONDITIONS FOR FIR2005-00020 1.) This operptio)i shall meet the minimum requirements of the Mason County Standards for the Operation of Retail Fireworks Stands (see attached). X An inspection by the Fire Marshal is required prior to opening on June 28th. 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 fof review and�ispection. OWN ER OR AGENT: DATE: FIR2005-00020 Please refer to the following pages for conditions of this permit. 2 of 3 -n CONCRETE MECHANICAL MANUFACTURED HOME Footings/Setbacks Date By Ribbons CD CD Date By Gas Piping Date By C Foundation Walls Date By CD Foundation oDate By INSULATION Date By Footings I Setbacks Floors FINAL I NSPECTION Date By Date By Date By FRAMING Walls FIRE DEPARTMENT Date By Date By Date By PLUMBING Attic OTHER Date By Groundwork Date By WALLBOARD NAILING Date By D.W.V Date By Date FINAL INSPECTION Date By Date By Water Line By Type of Insp. Pass/Fail Request Date Inspect. Date Done By Comments 0 CD � /6 _��p � o 0 3 -n z ^' Z CM Tif CD X 0 c D a c z o oX y � D M S .7' w 0 W r L/23/2004 14:20 FAX 360 427 7798 MASON CO PERMIT CTR 003/006 The folloviring 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 r designated ftlzy areas to: • Fire Hydrants • Property Lines • Buildings . pig i • Combustibles • Public Roads and Right of Ways Fire Lanes • Private Roads and Right of Ways • Trees/Biush • Landmarks • Utihues and Gas • Mortar separation distance • DeSipated landing area i i I i 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 be mai tal I n9o. S'gned 1 Date 'S 'Z.1 0�� FOR O + + CIAL USE ONLY BELOW THIS LINE ALCepted By: Date: i 2.vv5 ��Td.�-. rr i�E I�1 c�2►LS K- t1Ae_A,J`T tPAO �'V3E�F�4►iZ cEi➢-r"�� 6Y3 fi .vE. C�iF�o.J L✓ � "E7E L F,41 RL S tZ 3 0.3 LANv ScA N N FIR 6 JIM- -20K :30 . TE/,!T00 ' OQ b S�pq 4V_M V5 PHANTOM FIREWORKS TENT LAYOUT 20'x30' - F o is Ed 3' min. distance product to sidewall Exits 6' wide min. Lighting 1-3 overhead units or strings of lights inside perimeter Aisle width 44" min. Location notice of nearest phone at the register Exit signs above each exit E3 Extinguishers 3' 4' #4 Table Display #5 Table Display #6 Table 4' t Exit 6' #7 Table Display 6' Exit 4' # Table Display #2 Table Display #1 Table Display 4' 13 3' Fireworks will be displayed on 8' and 6' "banquet tables" with backup stock in original cases, beneath the tables, hidden from public by skirting. Fireworks on display will not have exposed fuses. If an item has exposed fusing that item will not be within reach of customers. Pallet displays will consist of original cases stacked with fireworks displayed on top of cases. Fireworks in original cases are packed "box within a box", boxes and labeled CFR 49 compliant. Tables: 7-8', 2-6' v a E Ing Fill Cr M M m I m N O I Certif trate of iftamr �r5iqtance 1 TAR +•`"��, REGISTERED ISSUED BY _ Oafs `7_q-4F� 9 Fabric Na. Meridian ManufacturingLn manufadvr�d 5050 Poplar Ave . , Ste . 1432 �geT�P =306,01 Alemph s , TN 38 1 57 m mThis is to certify that the materials described on the reverse side hereof have been Pame- rn retardant treated (or are inherently nonflammable). FOR Kev Manufacturing & Rental ADDRESS 5030 Rockdale St NE CITY Brooks STATE OR 97305 oCertificafion is hereby made that: (Check rra" or "b") a F� (o) The articles described on the reverse side of this Certificate have been treated with a flame-retardant chemical approved and registered by the State fire Marshal and that the application of said chemical was done in conformance with the laws of the State of California and the Rules and Regulations of the State Fire Marshal Nameof chemical used................................__....................................Chem. R#g. No........................... Methodof application-...... ..............--.......................................................... ............. ................... Q (b) The ortid" described on th+ rwerse skle h*r*a are nwde from a flame-resistant fabric or material registered cad approved by the Start* Fire Marshal for twcft use. LO Trade name of flame-resistant fabric ............... GrOUR I No. M 11605 Uj The dame Retardant Process Used_.,uTi.i_ .._not w t�I W wo . Be Removed By 'Washing D Q MARTY WHITE E Noma o!Applicator or Prodtid;on Svp4rinhnd*nt 7Jf� O FROM : BEAVER TENTS PHONE NO. 5033903625 Apr. 10 2003 11:38AM P3 CONTROL NO. 17p14 CUSTOMER ORDER NO. 5373 CUSTOMER INVOICE NO, 0085442-IN YARDS OR QUANTITY 1000. 0 linear yards COLOR_.,___ _ white STYLE 61 " Apex II Chrome DATE PROCESSED July 30 1997 B.J. ALAN COMPANY NORTHWEST (Distributor of Phantom® Brand Fireworks) Home Office: 555 Martin Luther King Jr,Blvd.,Younpato",Ott 44502 Phone(800)777-1591,fax(330)746.4410 Western Region Offices: 3215 56`1 St. NW,Ste.2A,Gig Harbor,WA 98335 Phone(253)853-5597,Fax(253)853-5925 8139 Elder Creek Rd,Sacramento,CA 95824 Phone(916)388-1479,fax(916)388-1476 3729-0,San Gabriel River Pkwy.Pico Riverar CA 90660 Phone(562)669-0505 Fax(562)699-0504 700 Kiernan Ave.,unit A,Modesto,CA 95356 Phone(209)491-5180 Fox(209)491-5188 124 West Burton Ave.SAIL Lake City,UT 84115 Phone(Sol)486.1516 Fax(801)486.4021 FIREWORKS LICENSE AGREEMENT This Agreement is made between Bel air Center LLC as Licensor, and B.J. Alan Company NW, LLC as Licensee, for the sale of 1.4g consumer fireworks at the,following Location: NAME: Vacant Pad 1 ADDRESS: SE Crnr Hiway 3&NE Clifton Lane ORDINANCE: Mason County CITY/STATE/ZIP: Belfair, WA 98528 The Location as listed above, is owned and/or controlled by the Licensor, and the Licensor grants to Licensee, and the group selected by the Licensee, the exclusive right to operate a temporary Fireworks Structure on these premises for the period: 3UNE 20, 2004 TO 3ULY 10, 2004 The exclusive right to operate a fireworks structure during the period stated above, with the same terms stated herein shall be automatically renewed through the year=. Should the location be sold or developed licensor may cancel this agreement with written notice to the licensee no later than April 1, of the current year. The Licensee agrees to the following terms and conditions: (1) Licensee will provide liability insurance coverage and provide to the Licensor, before occupancy, a certificate of insurance evidencinu ten million dolly in force covering the set-up, maintenance, and operation of the fireworks structure. The insurance shall name the Licensor as an additional Insured, and Licensee will hold the Llcensor harmless from any claims arising from the maintenance or operation of the structure. (2) Licensee shall pay all costs Involved in set-up, maintenance, and operation of the structure, and, on departure, the Licensee shall r4turn the premises to its original condition. (3) Licensee shall obtain and pay for all necessary permits and licenses required by law; shall post with local authority any debris or performance bonds, which might be required; and shall adhere to all laws and regulations. (4) If the sale of 1.4g consumer fireworks is prohibited by public authority, or if Licensee Is unable to secure a retail permit to operate on the property and the property is not utilized, the license amount prepaid will be refunded in a timely manner, and this license agreement shall automatically become null and void. If the local municipality having jurisdiction over this location limits the sale of 1.4g consumer fireworks or makes any local rules modifying the state statutes,then this license agreement Is subject to revision. .Q 5 If the roe is sold ingress/egress changed, a building permit Issued for construction or the like,than this license is subject to cancellation or revision. (6) Licensee shall Dav in full to Licensor within 15 days after receipt of a sinned copy of this agreement the minimum ~r License Fee of and a ► sales exceeding th breakpoint. Licensee shall '- deliver a sales statement to Licensor including any additional percentage rev uuv.,r „_,ust 5ei of the year indicated 0 above. AGREED AND DATED THIS DAY OF FC'Q , 2001. Licensor: 4 tgl� L,G Licensee: B.J. Alan Co an Signature: Signature:L, L--- Title: 4 V1 I?Y` Title: Director of Northwest Op eratio s a Address: Lab- I I ' nn � I-)"r't J ' J &, r .106 III . City/St/Zip: f G)r— U e- . On Phone/Fax: 42.5 54 44ZG 46S-Z87Z. EJ Corp. 9LLC ❑ Individual or Partnership Tax ID#/SSA#: *THIS AGREEMENT IS CONTINGENT UPON LICENSEE SECURING ALL LOCAL AND STATE LICENSES.* Td Wd90:t70 t700i? 176 9a3 ZLBZ+ssy+Sint? 'ON dNOHd ONI "dodd -1Ul:) I_9WW00 NOS331101 : W02id A RD. C E RT I F I CAT E DATE(MMIDD/YY) OF LIABILITY INSURANCE D5/20/Os PRODUCER 1-440-248-4711 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton-Gallagher & Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6240 SOM Center Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Solon, OH 44139 INSURERS AFFORDING COVERAGE Bruce Ball INSURED INSURERA:Arch Specialty Insurance Co. B.J. Alan Company Big Bear Fireworks, Inc. INSURER B:Lexington Insrrance Co. Phantom Fireworks :SURER Specialty Insurance Co. 555 Martin Luther King Jr Blvd Youngstown, OH 44502-1102 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONLTR LIMITS B GENERAL LIABILITY 2059307 10/30/04 10/30/05 EACH OCCURRENCE $ 1000000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) f 50000 CLAIMS MADE a OCCUR ME EXP(Any one person) $ PERSONAL&ADV INJURY f 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000 POLICY PRO X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT = ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC i AUTO ONLY: AGG f A EXCESS LIABILITY ULP0002485 10/30/04 10/30/05 EACH OCCURRENCE $4000000 X OCCUR F—ICLAIMS MADE AGGREGATE $4000000 S DEDUCTIBLE _ X RETENTION $10000 $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ E.L.DISEASE-POLICY LIMIT 1 E OTHER C Umbrella AAU704353 10/30/04 10/30/05 $5,000,000 $5,000,000 s s DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS PRODUCT LIABILITY EXTENDS ONLY TO PRODUCTS PURCHASED FROM S.J. ALAN COMPANY OR DIAMOND SPARKLER CO. INC. STAND LOCATION: VACANT PAD 1 AT SE CORNER OF HIGHWAY 3 & NE CLIFTON LANE, BELFAIR, WA 98528 ADDITIONAL INSUREDS: BELFAIR CENTER LLC; MASON COUNTY, ITS AGENTS, EMPLOYEES, AND OFFICIALS WHEN ACTING IN THEIR OFFICIAL CAPACITY CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION BELFAIR CENTER LLC 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 606 110TH AVENUE NE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE 206 REPRESENTATIVES, BELLEVUE, WA 9B004 AUTHORIZED REPRESENTATIVE USA ACORD 25-S(7/97) JenniferW V (BACORD CORPORATION 1988 2860924 Pow lBy TN Certificates Now _I APPLICATION FOR RETAIL FIREWORKS STAND PERMIT TO: Governing body of city, town, or county in which DATE OF fireworks stand will be located. APPLICATION: Applicant Name: Address, City, State: C/O BJ Alan Company T.E.E.N. 2367 Lincoln Ave Tacoma, WA 98421 Sponsor (If other than applicant): Address, City, State: Andrea Kozak 10808 144`h.Street NW Gig Harbor, WA 98329 Location of proposed fireworks stand: [Enclose drawing of stand location] l-ww 3 �0, Manner and place of storage prior, during, and after sales dates: All fireworks stored on site. State Licensed Fireworks Supplier: BJ Alan Company/Phantom Fireworks - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FIREWORKS STAND PERMIT For The Fireworks Sales Year Of: 2005 (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 IT&M UIVAM as the local governing authority,the named person, firm or organization is hereby a thorized to sell U.N. 0336 I AG Consumer fireworks at the location designated herein between the following date and times: Sales For July 41h Sales For December 31s' From: jyd, 2(j 1 From: To: To: Sponsor: Location: nutA Uyvq 3 1 N�- LVI /s/ /s/ Signature of Official Gra�ti�ngg Pgtrnit Signature of Applicant 5�73'� Ia/s;�gz77air/ .Q-o7Z� /ec'� _ ' le: Agency: Date: Permit Number: Licensee Name: I .L. .N• License Number:WSI EL-yIO2-4 Washington State Patrol 5579 g i Fire Protection Bureau Office Of The State Fire Marshal Washington State Fireworks License Fireworks Stand License Licensee Information License Is Non-Transferable And Valid For One Stand 2367 A Lincoln Avenue Date Of Issue: May 3, 2005 State Fire Marshal Tacoma, WA 98421- Expiration Date: January 31, 2006 Detach this wallet card and carry with you for verification of certification. Stand Information Washington State Patrol 5579 Contact Person: Andrea Kozak Fire Protection Bureau Office Of The State Fire Marshal Phone Number: (253) 396-0966 County Mason FIREWORK STAND LICENSE [Valid For One Stand] License Number: WSPFL-01027 Stand Number: SN-0001775 Licensee: T.E.E.N. Contact Person: Andrea Kozak Stand Number: SN-0001775 License Number: WSPFL-01027 ^ 2 1� Expiration Date: January 31,2006 Stand Location. 04"v? �J Location: _ on To Be Completed By Licensee] e . Stand Location To Completed y Licensee] 4 3000-420-012 (R 2/05) State Fire Marshal Signature Licensee Signature B.J. ALAN COMPANY NW PHANTOM FIREWORKS 2367 Lincoln Ave Tacoma, Washington 98421 Belfair - Mason County, WA Permit Checklist Belfair Center Item Amount Check Box State License -- /4ppLt -47-,�J d-G#c&JsE $40.00 � ye§ff No❑ N/A❑ Completed Fireworks permit a Yes No❑ N/A❑ Permit Fee $100.00✓ YesUf No❑ N/A[:] Site Plan Yes5ff No❑ N/A❑ Tent Plan Yes❑ No❑ N/Aig Certificate of Insurance YesX No❑ N/A❑ Property owner'spermission/ copy of lease agreement YesM No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No[:] N/A❑ Yes[-] No❑ N/A❑ Yes❑ No❑ N/A❑ Yes[-] No❑ N/A❑ Yes[:] No❑ N/A❑ Yes❑ No❑ N/A❑ Yes❑ No❑ N/A❑ Yes[:] No❑ N/A❑ Phone: 253.396.0966 Fax: 253.396.0771 ,/23/2004 14:20 FAX 360 427 7798 MASON CO PERMIT CTR W 002/006 Mason County Fireworks Permit Application PO BOX 186 Perm t# FIR 426 W Cedar St a Shelton WA 98584 Receipt 9d15 (360)427-9670 ext 273 CK # Date Received 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 nevi w. A permit will be issued upon satisfactory site Inspection by the Fire Marshal- 4plicant Info5�mation Name: ,1S77r _0,__ 1<0 ZC,.i(C- ,(-� ,� A) Mailing Address: S T ,A/I-) Cit State: zj (A Zip: cux 3.).cl Contact Number ( v) �7 i Sponsor Information Name: (af\. 69rjocj Iq `at e Ic.S Mailing Address: City: o State: ' f;J A Zip: �j q� I Contact Number Wfashington State Fireworks License Information (Copy Required) License No.: Date of Issue: g3105 Lj Pyrotechnic Operator License Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: C- Insured; rtified Holder: C '27 i Location of stand/display Jy Address: Directions to Re. Parcel Number: - y I -9 00 Legal Description: `l Legal Property Owner: 7 * * Please see the reverse side to complete your application I'L — -- -- - - - — — —