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HomeMy WebLinkAboutFIR2013-00017 Final Fire Works Stand - FIR Permit / Conditions - 6/27/2013 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 AN Phone: (360)427-9670, ext. 352 Mason County Bldg. 3 426 W. Cedar P.O. Box 279 Shelton, WA 98584 1� FIRE PROTECTION PERMIT FIR2013-00017 APPLICANT: TYSON DEVRIES RECEIVED: 5/22/2013 CONTRACTOR: LICENSE: EXP: ISSUED: 6/11/2013 SITE ADDRESS: 23940 NE STATE ROUTE 3 BELFAIR EXPIRES: 12/11/2013 PARCEL NUMBER: 123294190190 LEGAL DESCRIPTION: TR 19 OF NE SE LOT: C OF SIP#1059 PROJECT DESCRIPTION: FIREWORKS STAND GENERAL INFORMATION System Information Type of Use: STND Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 2 Hood& Duct?: N Flow Switches: Visual Devices: Door Releases: 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 I I II I I I I FIR2013-00017 Please refer to the following pages for conditions of this permit. Page 1 of 6 1.) Consumer fire works may be sold only on the `o.Iowing days and times. June 28th from 12 noon to 11 PM June 29th to July 5th from 9 AM to 11 PM July 6th from to 12 noon X Only State Fire Marshal approved class C common fire works may be sold. X �V�MI 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 liquid or gas dispensing device, or 300 feet from any flammable liquid or gas bulk storage or dispensing facility. X 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 area shall be d and flagged. X Motor vehicl s or trailers may not be parked within 20 feet of the fire works stand except when delivering, loading or unloading fireworks. X Fireworks shall not be discharged within 300 feet of any fireworks stand. A sign stating "No Fireworks discharge within 300 feet' in letters at least 2 inches high and inraptrasting color shall be posted conspicuously on all sides of the structure. X 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 in contrasting co ors shall be posted conspicuosly on all sides of the structure. X All battery powered equipment, electrical equipement and cords shall be UL listed and used in accordance with that listing. Extension cords shall be of an industrial gra t and shall be protected from physical damage. X 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 elemen eating devices are prohibited. X Generators fl-bg located a minimum of 20 feet from any fire works stand. Fuel storage is limited to 5 gallons. X A minimum 24 inch 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 inches in width located at oppsite ends of the stand. These exits shall remain unlocked and unobstructed during hours of operation or when stand is occupied. X Sleeping4i e�aa�fireworks stand is prohibited. FIR2013-00017 Please refer to the following pages for conditions of this permit. Page 3 of 6 X 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 emerge ne number, 911, and the address of the fireworks stand shall be conspicuously posted inside the stand. X There shall a minimum of 2 approved 2 1/2 gallon pressurized water fire extinguishers located adjacent to each exit door. X Cooking, opepJLame or any type of open flame equipment is prohibited in a fireworks stand. X 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 and permit_ X �--� 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, barn or other accessary building that is at least 20 feet from the fireworks Stan X 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 tha age of 16 shall be allowed to occupy the fireworks stand when open to t attc. Ili X I jIt is illegal to knowingly sell fireworks to persons under the age of 16. A sign stating "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 responsiblity,of the seller to require proof of age. Qrbwls license or photo ID showing date of birth issued by a public or private school, state, federal or foreign government is acceptable. X o- 2.) Owner/A en responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28. X 3.) Valid Permit a on-site. 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 owner or the agent on the owners behalf, represents that the information provided is accurate and grants employees of Mason County access to the abo scribed property and structure for review and inspection. OWNER OR �ENT- DATE: [o - l2 FIR2013-00017 Please refer to the following pages for conditions of this permit. Page 4 of 6 v N CONCRETE MECHANICAL MANUFACTURED HOME m Date B r X Footings !Setbacks Ribbons �� __. —�� Gas Piping m OInterior Date By Interior-Date By Date _ M_- By _ (n (D Exterior Date By Exterior-Date t3y sat-up INSULATION y Point Load 1 Isolated Footings Date BG I SLAB INSULATION - O Data ey Data By FIRE DEPARTMENT Z Foundation Walls Floors Date !iy Date BY Date By DECKS --.--_-_ FRAMING Walls Date By Date By Data By PROPANE TANKS PLUMBING vault Date By Date By OTHER Groundwork Attic Type. Dale By Date By Date By D.W,v DRYWALL type In4 Brace Wall Date Fly � Date By Date By -- ___._—_ X y FINAL INSPECTION c O Water Line Fire Separation a Date By Date By Dale By C o Pass or Request Inspect. o Type of insp. Fail Date Date Done By Comments 0 G—2J# ' -.2 7' f 5' co to to N M O A O 7 o' lA O 3 N A 3 r: sv m Cn 0 rn APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWH6552 TO: Governing body of city,town, or county in which DATE OF 103.12.13 fireworks stand will be located. I APPLICATION: Applicant Name: Address, City,State: BELFAIR ASSEMBLY OF GOD 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Sponsor(If other than applicant): Address, City.State: TYSON DEVRIES 2120 MILWAUKEE WAY, TACOMA„ WA 98421 Location of proposed fireworks stand: [Enclose drawing of stand location] 23940 NE SR 3 BELFAIR, WA RITE AID#6544 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 Julv 4 h Sales For December 31s' From: From: To: To: Sponsor: BELFAIR ASSEMBLY OF GOD Location: RITE AID#6544 23940 NE SR 3 BELFAIR. WA /s/ /s/ -ba�amka FOR TYSON DEVRIES Signature of Official Granting Permit Signature of Applicant Title: Agency: Date: Permit Number: Licensee Name: BELFAIR ASSEMBLY OF GOD License Number: 00848 3000-420-013(Rev.2105) ACC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) Il/l/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). CONT PRODUCER Lockton Companies,LLC NAMEACT 3280 Peachtree Road NE,Suite 800 PHONE Fax A/C No Ext: A/C 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. INSURERC: P.O.BOX 1318 INSURER D: 4511 Helton Drive INSURER E Florence AL 35630 INSURER F: COVERA CERTIFICATE NUMBER: 12253475 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN SR WVD POLICY NUMBER MMIDDIYYYY MM/DDIYYYY A GENERAL LIABILITY Y N CPS1612503 I1/1/2012 11/l/2013 EACH OCCURRENCE DAMAGE TO RENTED X MMERCIAL GENERA (ABILITY PREMISES(Ea occurrence) $ 100,000 CLAIMS-MADE I XOCCUR MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000A0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- $ JECT X LOC AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMI1 (Ea accident) $ XXXXXXX ANY AUTO BODILY INJURY(Per person) $ XXXXXXX ALL OWNED SCHEDULED BODILY INJURY Per accident $ XXXXXXX AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ XXXXXXX HIRED AUTOS AUTOS (Per accident) $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ }(}{J{){XXX EXCESS LIAB CLAIMS-MADE AGGREGATE $ }(}{}{}{XXX DED RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ XXXXXXX OFFICERIMEMBER 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 $ }(}(X){XXX DESCRIPTION OF OPERATIONS/LOCATIONS/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 Rite Aid#6544 23940 NE SR 3 Belfair,WA(W WH6552)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. 12253475 AUTHORIZED REPRESENTATIVE Mason County Belfair Assembly of God Youth 426 W Cedar Shelton WA 98584 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD '© 988- 10 CORD CORP TION.All rights reserved I l� I- cos 2- FIREWORKS LEASE AGREEMENT This agreement Is made between Thrifty Pa&N Ina,Lessor and AMERICAN PROMOTIONAL EVENTS NORTHWEST as Lessee. 1. AMERICAN PROMOTIONAL EVENTS-NW,will lease a portion of the property located at$tom 65ft 239411 NE Stall Route r;b.Belfmir. WA !or the sale of approved fireworks from the following premises(hereafter called the°Location"): 2. The lease payment will bt _ r year for the period of June 20ei titre July g'"hereafter called the "Season". Payment shall be pald on o, uefore Janutl19i'1_, 3. Lessor represents that the Location Is owned and/or controlled by the Lessor and furthermore that the Lessor agrees to grant the Lessee the exclusive right to operate a fireworks sales structure(hereafter the"Structure') through the year 4a15 or the above-mentioned period. 4. The Lessor herby grants Lessee a first right of refusal to match any bona fide offer to lease the Location for fireworks sales during the renewal Seasons. S. in return, Lessee agrees to the following terms and conditions: a. Provide an A+rated$10,000,000.00 certificate of insurance,prior to occupancy,evidencing liability insurance In force covering the erection and operation of the Structure.Insurance shall name Lessor as additional insured,and Lessor shall be held harmless from any claims arising from the maintenance or operation of the Structure. b. Pay any and all costs Involved in erection,maintenance,and operation of the Structure,and Lessee shall guarantee that the Location will be returned to its original condition. c. Obtain and pay all necessary permits and licenses required by law,post with local authority any debris or performance bonds as required,and guarantee that all laws and regulations shall be adhered to. 6. This agreement is contingent upon Lessee securing necessary permits and licenses. Lessee may cancel this agreement If the sale of fireworks is prohlbited at this Location by a public authority or such sale,In the good faith opinion of Lessee,becomes commercially unreasonable. In such an event any deposit shall be refunded to Lessee. Agreed to and dated thi day of au"�" , 2012 Accepted: ~` I Accepted: r Lessor: Rob Lambracht Lessee: Ke neth A. Spence Thrifty Payless Inc. AMERICAN PROMOTIONAL EVENTS-NW 14625 SW Allen Blvd.,Suite 101 Beaverton,OR 97007 Phone:$03-520-7206 AMERICAN PROMOTIONAL EVENTS,INC. I \i 2120 MILWAUKEE WAY•TACOMA,WA 88421 TACOMA(283)9=-NW.8EATTLE(263)838-1099 FAX(263)830.2030 www.tm8rewcrke.aom I 1 2-0 13 Washington State Patrol W WT\ `✓'= 14321 Fire Protection Bureau Office Of The State Fire Marshal Fireworks Stand License Washington State Fireworks License License is Non-Transferable and Valid for Only One Stand Licensee Information f�, Belfair Assembly of God 2120 Milwaukee Way State Fire Marshal Sign t �• Tacoma, WA 98421 License Number: WSPFL-00848 Detach this walletraar '6dacatry with you for verification of certification. Stand Information Washington State Patrol 14321 Contact Person: Tyson Devries Fire Protection Bureau Office Of The State Fire Marshal Phone Number: (360) 277-3778 ANNUAL FIREWORKS STAND LICENSE County: Mason Date of Expiration Date of Issue Licensee: Belfai ...ssern l of God Stand Number: SN-07282 January 31, 2014 January 17, 2013 Contact Person: TyslrDevnes License Number: W3PlUd848_',x Stand Number: SN tl $2' rt id For One Stand] Date of Expiration: Jan' . Location: �r. Stand Location: L",andLoc,tion mpleted By Licensee) [Stand Location To Be Completed By Licensee] 3000-420-012(R 9/05) State Fire Mars '� ignature Licensee Signature ' SITE DIAL"M Date Updated: Location #: w VV R U5C�22 Location Name: ?f A-� Ordinance Of: Mn,,Z N1 C aL� V1 Site Address: 1'��H 0 N �, Sn Structure Size: CITY 6e�-� ) STATE/ZIP 'IN Structure Faces: Parcel: Show ali setback r s r,-c tar. C z private property d .� t� ul�r, structures, �,: fire i�,n�,�, �.Ibii.: and ��rivat._ roads, arQ ,L ices r��ee; and 4GESNE IT FOR APPROVAL PRIOR TO PERFORMING WORK �YaL$5 ISPk UJ - ;Or ���I TL �' Lre.f I r Notes MASON COUNTY FIRE MARSHAL I Mason County Bldg. III 426 W Cedar St PO BOX 186 Shelton,WA 98584 qgIg (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 28th from 12 noon to 11PM • June 29t"—July 5th from 9AM to l lPM • July 6th from 9AM to 12 noon • December 27th—3 1" from 12 noon to 11PM 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. Ty 1z32 '�Fl y� 20 / - 000 COP `' THESE PLANS MUST BE ON THE JOB SITE FOR INSPECTION. ApprioVEM MASOOY FIRE M SH L DATE 2` BY SUBJECT TO FIELD INSPECTION ALL APPLICASL CODES A4ALL APPLY. ERRORS AND/OR OMISSIONS ON PLANS ARE SOLE RE SPONSIBILITY OF OWNER•%CONTRACTOR. CORREC- TIONS REQUIRED FROM FIELD INSPECTION SMALL BE AT OWNER/CONTRACTOR'S EXPENSE. THIS AP- PROVAL DOES NOT GRANT TO ANY PERSON Tilr RIGHT TO VIOLATE ANY CCTV OF- STATE l.!'•.':;. if i . WWH6552 Mason County Fireworks Permit Application PO BOX 186 Permit # FIRA5 426 W Cedar St Shelton WA 98584 Receipt # (360) 427-9670 ext 273 CK #,3X j,2B2Zj Date Received c5- - 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: TYSON DEVRIES Mailing Address: 23001 NE STATE RT 3 City: BELFAIR State: WA Zip: 98528 Contact Number (360 ) 275-2858 Sponsor Information Name: BELFAIR ASSEMBLY OF GOD YOUTH Mailing Address: 23001 NE STATE_ RT 3 City: BELFAIR State: WA Zip: 98528 Contact Number (360 ) 277-3778 Washington State Fireworks License Information (Copy Required) License No.: Date of WSPFL-00848 Issue: 01/17/2013 ❑ Pyrotechnic Operator License ❑Q Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/ Bond Required) Provider: SEE ATTACHED INSURANCE Insured: Certified Holder: Location of stand/display Address: RITE AID #6544 23940 NE SR 3 BELFAIR, WA Directions to Site: Parcel Number: 1 ��2q - 141 - Q Legal Description: Legal Property Owner: RITE AID * * Please see the reverse side to complete your application The following 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 desi sated display 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 + Designated landing area **PLEASE SEE ATTACHED DIAGRAM 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 maintained. Signed FOR TYSON DEVRIES Date 05/2013 FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: