Loading...
HomeMy WebLinkAboutFIR2008-00034 Final Fireworks Stand - FIR Permit / Conditions - 6/28/2008 55 CONCRETE MECHANICAL MANUFACTURED HOME X Pa m Q By Date 0 0 Footings /Setbacks Gas Piping Ribbons ;0 co Interior Date By interior-Date By Date By 0 Q Exterior Date By Exterior-Date X Q set-up CA INSULATION 0 Point Load I Isolated Footings Date By Date By BG I SLAB INSULATION -1-,------1-1—-- 7 Date By FIRE DEPARTMENT 0 Foundation Walls Floors 0810 By m y Date B D DECKS ata By C 0 FRAMING Walls Date By X Date By Data By PROPANE TANKS PLUMBING Vault Date By OHIO By OTHER Groundwork Attic By Type- Date By Data By 0V.1v DRYWALL T ype 71 Int Braco Wall Date By — Date 8 -- y Date By X FINAL INSPECTION Water Line Firo Sepo ration C) 0 Datu By 0.110 By 00 Date By I Q 0 Pass or Request I Inspect. of Insp. Fail Date Date Dane By Comments 9WT I m Type 6 rjAffw&4-" Ay lxldf!&Al Cnt)Avn1 6 FlArr Ay,�v TO ALtyvy-av S A4,50 401-'z;,r cn 0 m O MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)t27-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext.352 Shelton,WA 98584 FIRE PROTECTION PERMIT FIR2008-00034 APPLICANT: CHUCK FREDRICKSON RECEIVED: 5/20/2008 CONTRACTOR: LICENSE: EXP: ISSUED: 5/23/2008 SITE ADDRESS: ............................... EXPIRES: 11/23/2008 PARCEL NUMBER: 123294190022 LEGAL DESCRIPTION: TR 2-6 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?: N Dry Chemical?: N Pressure Switches:: Smoke Detectors: Duct Detectors: 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 FIR2008-00034 Please refer to the following pages for conditions of this permit. 1 of 4 CASE NOTES FIR2008-00034 CONDITIONS FOR FIR2008-00034 1.) Applicant shall meet minimum requirements of the Mason County Standards for the Operations of Retail Fireworks Stands (see attached). , X Inspection by the Fire Marshal required before opening. X 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 for review and inspection. OWNER OR AGENT: DATE: FIR2008-00034 Please refer to the following pages for conditions of this permit. 2 Of 4 MASON COUNTY Department of Community Development FIRE PROTECTION SYSTEMS INSPECTION CARD* PO BOX 186, 426 W Cedar ST, Shelton WA 98584 General Questions: (360) 427-9670 ext 352 Inspection Requests: (360) 427-7262 Permit Number FIR2008-00034 Date 05/23/2008 Issued By Project Fireworks Stand. Site Address ............................... Applicant CHUCK FREDRICKSON Contractor License Number Con. Phone Expiration Date Primary Code 2004 IFC Wet Chem N Sprinkler IN Use STND Dry Chem N Standpipe N Hod and Duct N Public Works Access/Driveway Other Health Dept Septic Well Planning Dept Site Inspection Fire Marshal Fire Apparatus Access Fire Sprinkler Auto Fire Alarm Hood and Duct Other Final Building Dept Building Official: Barbara Robinson Concrete Setbacks Slab Footing Perimeter Ret. Wall / Bulkhead Footing Interior Footing Decks/Porches Foundation Stem Other Rough-In Groundwork Plumbing Plumbing Groundwork Mechanical Other Groundwork Gas Pipe Gas Piping Framing Mechanical Insulation Slab Ceiling Floor Vaulted Ceiling Walls Vapor Barrier Other Wallboard Nailing Interior Wall Brace Panels Fire walls Other Final Building Manuf. Home Setbacks Setup • Concrete Foot/ Runners Final Other APPROVED PLANS MUST BE ONSITE FOR ALL INSPECTIONS *THIS STRUCTURE MAY NOT BE USED FOR OCCUPANCY UNITL ALL APPLICABLE FINAL INSPECTIONS ARE COMPLETED DO NOT PROCEED BEYOND EACH STAGE OR COVER WORK UNTIL APPROVALS ARE GIVEN. POST THIS CARD IN A CONSPICUOUS PLACE ON THE FRONT OF THE PREMISES CONVENIENT FOR MAKING REQUIRED ENTRIES. ALL PERMITS EXPIRE 180 DAYS AFTER PERMIT ISSUANCE OR 180 DAYS AFTER LAST INSPECTION ACTIVITY IS PERFORMED. OWNER/AGENT IS RESPONSIBLE FOR CALLING FOR ALL INSPECTIONS PRIOR TO CALLING FOR FINAL INSPECTION ALL CONDITIONS OF THE PERMIT MUST BE MET. 01/23/2004 14:20 FAX a60 427 3 )LkSON CO FLRMIT CTR (Jd02/dUR Mason County Fireworks Permit Application PO BOX 186 Permit#fi FIR ��c,,� � � )(4 426 W Cedar St Shelton WA 98584 Receipt # S � (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 revi�w. A permit will be issued upon satisfactory site Inspection by the Fire Marshal. Applicant Information Mailing Address: -a.�v �- 5 j f o d v .eA - v ,e, City: AL-d Pd Contact Number N n State: Sponsor information Name: /V A Mailing Address: City: State: Zip: 06n1act Number ( ) Wlashington State Fireworks License Information (Copy Required) License No.: Date of ( by . I gicox Issue: 0 Pyrotechnic Operator License ` Fireworks Stand License Band or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: Insured: .A L o Y1 C rtiiied Holder. , � CP11 _LC �.. Location of stand/display Address: SE Oaner Idy Bid Fd1 & ICE Cliftrn Ln, Belfair, to 98528 j Directions to Site: 7-7 " - Parcel Number: 12329-41-9�OCe2 ir Legal Description: M 2929 a rL ! Legal Property Owner: Md blefson a yC 71r 1 � / I LL O z i Please see the reverse side to coMplete your appliq cl „ Zug, c) n O W m aCynC QOn t G G 01/23/2004 14:20 FAX 360 427 3 MASON CO PERMIT CTR o 003/006 v I The followinLy vertinent information MUST be provided on the site diagram below Locations and Setback distances from the back,sides and front of retail sales stands or designaed display areas to. j • Fire Hydrants • Property Lines • Buildings • Parking i • Combustibles • Public Roads and Right of Ways • Fire Lames • Private Roads and Right of Ways + Trees/Brush • Landmarks • Utilities and Gas • Mortar separation distance • Designated landin area wee o. i 4plicants 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 maintained. \ Sjgned ;� ��1.� - �- 1_ Date — I FOR O + CL&L USE ONLY Bi,LOW THIS LM A6cepted By: Date: 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: 2367 Lincoln Avenue, Tacoma, WA 98421 tc A Sponsor (If other than applicant): Address, City, State: Location of proposed fireworks stand: [Enclose drawing of stand location] we U Ao n L Xi k QE —&3cl�ck Manner and place of storage prior, during,hnd after sales dates: No Storage State Licensed Fireworks Supplier: B. J. Alan Company NW/ Phantom Fireworks - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - FIREWORKS STAND PERMIT For The Fireworks Sales Year Of: 2008 (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 as the local governing authority, the named person, firm or organization is hereby authorized to sell U.N. 0336 1.4G Consumer fireworks at the location designated herein between the following date and times: Sales For July 4th Sales For December 315t June 28, 2008 From: From: Julv 05, 2008 To: To: Sponsor: e-1-1 � 4,19 � Location: " cxb -� Lmt K "o &Q& /s/ /s/ Signature of Official Granting Permit Signature of Applicant Title: Agency: Date: Permit Number: Licensee Name: License Number: 3 ev. RETAIL FIREWORKS STAND PLOT PLAN Fireworks Product Wholesaler: Phantom Fireworks - (253) 396-0966 Fax (253) 396-0771 N 2367 Lincoln Ave., Tacoma, WA 98421 Organization Name: ACCT # r Stand Location: Belfair Center Tent Size: 30X50 Tent Entry/Sign Pkg.: Yes - Stand Address: Not Up Before: 6/25 Down By: 7/6 Stand City Belfair, WA Local Contact Name: Phone: . - 0001 Roy '1 Road r 150 ♦ N STORAGE Parking Area N 25' 25' 30x50 TENT Bush 25 PHANTOM FIREWORKS TENT LAYOUT 30'x50' Exits 6' wide Lighting 2-3 overhead units or strings of lights inside perimeter Aisle width 44" Location notice of nearest phone at the register Product to sidewall 3' min. Exit 13Extinguishers Exit signs above each exit 4 -- 16'—► 3' 3' - #9 Table Display #1cTable Display #1:Table Display #1,Table Display Co Cr ail a Pallet Pallet No. 4 No. 1 #17 Table Display #18 Table Display #16 Table Display #15 Table Display Pallet Pallet No. 3 No. 2 < > En #ETable Display #ETable Display #2Table Display #1Table Display 3' 3' Exit �-— 6' —� 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: 16-8', 4-6' B.J. ALAN COMPANY NORTHWEST (Distributor of Phantom° Brand Fireworks) Home Office: 555 Martin Luther King Jr. Blvd.,Youngstown, OH 44502 Phone(800)777-1691, Fax(330) 746-4410 Western Region Offices: 2367A Lincoln Ave.,Tacoma,WA 98421 Phone(253)396-0966, Fax(253) 396-0771 8139 Elder Creek Rd,Sacramento,CA 95824 Phone(916) 388-1479, Fax(916) 388-1476 3729-D,San Gabriel River Pkwy. Pico Rivera,CA 90660 Phone(562) 669-0505 Fax(562) 699-0504 700 Kiernan Ave., Unit A, Modesto,CA 95356 Phone(209)491-5180 Fax(209)491-5188 124 West Burton Ave. Salt Lake City, UT 84115 Phone(801)486-1516 Fax(801)486-4021 FIREWORKS LICENSE AGREEMENT This Agreement is made between Belfair Center LLC as Licensor, and B.J. Alan Company NW, LLC as Licensee, for the sale of 1.4g consumer fireworks at the following Locat' n: Roy C3ao�lnogd NAME: Belfair Center ADDRESS: SE Corner and NE Chfto La eCPQd 3 lof l�'71ol; ORDINANCE: 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: JUNE 15, 2006, THROUGH JULY 15, 2006 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 years 2007, 2008, and 2009. 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 evidencing the insurance 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 Licensor 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 return 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 y having jurisdiction over this location limits the sale of 1.4g consumer fireworks or makes any local rules modifying the state statutes, thep this,license agreement is subject to revision. SS) If th !2roper�s soles � ss/egress changed, a building permit issued for construction or the like, than this license is subject to cancellation or revision. Should cancellation or revision occur, Licensee will be given first right of refusal to conduct the sale fireworks at the location listed above during the term of this agreement. It (6) Licensee shall pay in full to Licensor within 30 days after receipt of a signed copy of this agreement the minimum License Fee of $_ d a _ :_% fee on sales exceeding the $_ __ breakpoint. Licensee shall deliver a sales statement to ucen o including any additional percentage fee due by August 5" of each year. 6 AGREED AND DATED THIS - DAY OFy� ze- Licensor: Qk . , ' 'J. f' "� Licensee: B.J. Alan Com an NW LLC Zd J f Signature: I— ct G� %. ra Signature: ,_ f Title: i11 L' V'F" Title: Director of Northwest Operations Address: t '� -` ? I I c City/St/Zip: Phone/Fax: ❑ Corp. N�LLC ❑ Individual or Partnership Tax ID#/SSA#: *THIS AGREEMENT IS CONTINGENT UPON LICENSEE SECURING ALL LOCAL AND STATE LICENSES.* T Of �( G� eR MISTMD t l APPt.rJMN FSSIISD By Data tractor or „0 Avalon Tent Manufacturing manufactured �• ya '� �_ERN m 14928 Shoemaker Ave. 04/27/2007 !!!� F419.01 Santa Fe Springs, 90670 This is to certify that the F raterials described tielow hereof have been flame retardant treated!or are inherently rranfla able). f FOR AA Party Rentals ADD} ESS 6404 216th. Street Syr' Mountlake STAT� WA 98043 Cerf ficatior� �s hereb de that:(Chec "a"or"b") ;2;• ze articles described b i w this certificate he a been treated with a flame-retardant chemical lt approved and registEred bythe State Fire Marsitat and that the application of said chemical it` was done in conformance with the laws of the State of California and the Rules and Regula- ill lions of -+ ... ,he State Firem. ,I shaf. I Name of cherr!ica:used .. Chem.Reg.Na. Mc-' od ai application. ....................................... .................................................................... _.. X h` —!e articles described b low hereof are made frbm a flame-resistant fabric or material regis- �eretandarmrovedbvff State Fire Marshal fair such use; Fabric has been tested and passes N=7 G?011-96. ? ­ade :tame ct flarne-re i tant fabric or materia�used ..�M-TE.X. Reg. No.F419. 01 ? Tie °ame Retardant rocess Used ... '�tl.v�t. .Be Removed by Washing j (wit or will not) 5 ( Vince Rosato By Cathy M. Kaplan Diaz r'r.rr;e o:�p�li�tnr or?ror on Superi arndant T-itlecont— ler i Canopy Top 20x20 I-pc White B/c Canopy Top 20x25 1-pc White B/O Canopy Top 20x30 I-pc White B/O COt,,TR0L NI0. 12 219 Canopy Top 20x40 I-pc While B/O 165 3443 Canopy Top 20x202-pc White 310Lcc JS`0MEE^ ORDER NO. Ccnopy Middle 20x5 White B/O Lace Ci.iSTOMER !i�:VOICE NO. 7 7 6 Canopy Middle 20x10 White B/O Lace 91050 Canopy Middle 20920 White 610 Loce YP.-;DS OR QU-,'VT!TY Canopy Top 30x30 1-pc White B/O COLOR _ _ _ Wh-ite B Polish Canopy Middle 30x10 While B/O Lace 1 61 Canopy Middle 30x15 white B/0 Lace STY E Canopy Top 40x40 2-pc White B/O Lac Canopy Middle 40x10 White 8/0 Loce GATE PROCESSED 04-2 �2007 Canopy Middle 40x20 White B/O Loce Rain Gutter 10 Ft,White B/O Rain Gutter 15 Ft_White B/O Rain Gutter 20 Ft.White B/O Rain Gutter 30 Ft.White B/O Rain Gutter 40 Ft.White B/O Side Woll 10x15 White With Window Side Wall I0x20White With Window ACORD,M CERTIFICATE OF LIABILITY INSURANCE 1DATE/15M/DD/Y20077 11 15 PRODUCER Phone: 440-248-4711 Fax: 440-248-5406 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION— Britton-Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cleveland OH 44139 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED B.J. ALAN COMPANY INSURER A:Lexington Insurance Co BIG BEAR FIREWRRKS, INC. PHANTOM FIREWORKS INSURERS: 555 MARTIN LUTHER KING JR BLVD INSURERC: YOUNGSTOWN OH 44502-1102 INSURERD: 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 ADO'L POLICY EFFECTIVE POLICY EXPIRATION INSRE3 TYPE OF INSURANCE POLICY NUMBER LIMITS A GENERAL LIABILITY 6990330 10/30/2007 10/30/2008 EACHOCCURRENCE $ 1,000,000 -5TgA-CE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $5 0 000 CLAIMS MADE a OCCUR MED EXP(Anyone person) $ PERSONAL 8 ADV INJURY $ 11000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OPAGG $2,000,000 POLICY PRO X LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALLOWNEDAUTOS BODILYINJURY = SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ a DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATUS LIMITSOTH- EMPLOYERS'LIABILITY EACH ACCIDENT $ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS C USIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS STAND LOCATION: SE CORNER ROY BOAD ROAD AND CLIFTON LANE PAD #3, BELFAIR, WA 98528. DATES OF OPERATION: JUNE 20TH, 2008 TO JULY LOTH, 2008. DDITIONAL INSUREDS: MASON COUNTY, ITS AGENTS, EMPLOYEES, AND OFFICIALS WHEN ACTING IN THEIR OFFICIAL CAPACITY. roup Code: TACOMA WA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BELFAIR CENTER LLC BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE BELFAIR CENTER PARKING LOT CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO 16650 NE - 79th STREET, SUITE 103 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON REDMOND WA 98052 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE , ACIDRD 25(2001/08) ©ACORD CORPORATION 1988 B.J. ALAN COMPANY NW PHANTOM FIREWORKS 2367 Lincoln Ave., Tacoma, Washington 98421 May 4, 2006 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 attendants) 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 ch over the fireworks will be covered at Fireworks Retail Orientation Workshops, mandatory attendance with every group associated with the sale of Phantom Fireworks. 3hone: 253.396.0966 Fax: 253,396.0771 Washington State Patrol 9 141 Fire Protection Bureau Office Of The State Fire Marshal Fireworks Stand License Washington State Fireworks License License is Non-Transferable and Validfor Only One Stand Licensee Information Charles L. Fredrickson 2367 Lincoln Avenue State Fire Marshal Signature Tacoma, WA 98421 License Number: WSPFL-01469 Detach this wallet card and carry with you for verification of certification. Stand Information -Washington State Patrol 9141 Contact Person: Charles L. Fredrickson Fire Protection Bureau I Office Of The State Fire Marshal Phone Number: (360) 876-6465 1 ANNUAL FIREWORKS STAND LICENSE County: Mason Date of Expiration Date of Issue Licensee: Charles L.Fredrickson Stand Number: SN-03456 January 31,2009 May 2, 2008 Contact Person: Charles L. Fredrickson License Number: WSPFL-01469 Stand Number: SN-03456 [Valid For One Stand] 9; I Date of Expiration: Jarivary 31,2009 Stand Location: I Location. I �. to Loc To Completed By Licensee) [Stand Location To Be Completed By License ! c% f B.J. ALAN COMPANY NW PHANTOM FIREWORKS 2367 Lincoln Ave.,Tacoma, Washington 98421 Mason County R E C E I V Fireworks Permit Application ,#Oj 1. 6 48 Ili a 60lication for Fireworks Stand permit for the 2008 season. Stand Location: NE Clifton Lane & NE Roy Boad Road, Belfair, WA 98528 Group Name: Chuck Fredrickson Contact Person: Chuck Fredrickson Address: 3095 SE Hoover Ave., Port Orchard, WA 98366 Mailing Address: 2367 Lincoln Ave. Tacoma, WA 98421 Phone: (360) 876 - 6465 Whsl. Supplier: B.J Alan Company Northwest / Phantom Fireworks State License#: 9141 Individual completing Application Packet: Name: Jasmin Slaughter Phone: (253) 396 - 0966 Requirements Item Amount Check # Check Box State License $40.00 Yes ® No ❑ Fireworks Permit $100.00 235107 Yes ® No ❑ Fireworks Permit Application Yes ® No ❑ Site Plan Yes ® No ❑ Tent/Stand Plan Yes ® No ❑ Certificate of Insurance Yes ® No ❑ Certificate of Flame Resistance Yes ® No ❑ Property Owner'spermission/copy of lease agreement Yes ® No ❑ Directions to Site Location Yes ® No ❑ State Patrol Application Yes ® No ❑ Night Security Yes ® No ❑ PhnnP• qsn 3gR ngfiR Fay- 253 3gR n771