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HomeMy WebLinkAboutFIR2014-00020 Fireworks Stand - FIR Permit / Conditions - 6/27/2014 PMASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line (360)427-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 279 Phone: (360)427-9670, ext. 352 Shelton, WA 98584 ro FIRE PROTECTION PERMIT FIR2014-00020 APPLICANT: NORTH MASON PEE WEES RECEIVED: 6/24/2014 CONTRACTOR: LICENSE: EXP: ISSUED: 6/27/2014 SITE ADDRESS: 23969 NE STATE ROUTE 3 SUITE BELFAIR EXPIRES: 12/27/2014 PARCEL NUMBER: 123294190021 LEGAL DESCRIPTION: TR 2-A OF NE SE LOT: 1 OF SP#2929 PROJECT DESCRIPTION: FIRE WORKS STAND GENERAL INFORMATION System Information Type of Use: RES Sprinkler Heads: Audible Switches: Pull Stations: Fire District: 2 Flow Switches: Visual Devices: Door Releases: Hood & Duct?: N 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?: Third Floor,: Total: $100.00 $100.00 FIR2014-00020 Please refer to the following pages for conditions of this permit. Page 1 of 4 CASE NOTES FIR2014-00020 CONDITIONS FOR FIR2014-00020 1.) Per section 901.2.1 of the 2012 International Fire code, Statement of Compliance. Before requesting final approval of the installation, the installing contractor shall furnish a written statement to the fire code official that the subject fire protection system has been installed in accordance with the approved plans and has been tested in accordance with the manufactures specifications and the appropriate installation standard. Any deviations from the design standards shall be noted and copies of the approvals for such deviations shall be attached to the written statement. X OWNER/ BUILDER acknowledges submission of inaccurate information may result in a stop work order or permit revocation. Acknowledgement of such is by signature below. I declare that I am the owner, owners legal representative, or contractor. I further declare that I am entitled to receive this permit and to do the work as proposed. I have obtained permission from all the necessary parties, including any easement holder or parties of interest regarding this project. The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above described property and structure(s) for review and inspection. This permit/application becomes null &void if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION. INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION. Signatur4 Date OWNER - REPRESENTATIVE - CONTRACTOR Print Name (Circle one to indicate) FIR2014-00020 Please refer to the following pages for conditions of this permit. Page 2 of 4 -n Z N CONCRETE MECHANICAL MANUFACTURED HOME 0 O Date By __ X Footings /Setbacks Gas Piping Ribbons = CInterior Date By interior-Date By Date By C ic Exteror Date By Exterior-Date _ B Set-up > O Point Load I Isolated Footings INSULATION Date By O BG I SLAB INSULATION - mm Z Date By Data By FIRE DEPARTMENT Foundation Walls Floors Date By M M Date By Data By DECKS FRAMING walls Date By m Date By Data By PROPANE TANKS N PLUMBING vault Data By Date By OTHER Groundwork Attic Type- Data By Date By Date By D.w.v DRYWALL Type_ Int.Brace Wall Date By T Date By Date By 55 FINAL INSPECTION N y O M Water Line Fire Separation Date By Date By Date By P O 0 Pass or Request Inspect. c Type of Insp. Fail Date Date Done By Comments c 0 o 3 a1 f0 fD 0 O 0 O 7 a 0 3 0 y M fD iU fD W O A Mason County Fireworks Permit Application PO BOX 186 Permit# FIR d201Lf_ 426 W Cedar St Shelton WA 98584 Receipt #5220 R-14V (360) 427-9670 ext 273 C K #) " (- Date Received to 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: RAYMOND MOW Mailing Address: 302 NE HAVEN LAKE DR City: TAHUYA __ State: WA Zip: 98588 Contact Number ( ?53) 208-2235 Sponsor Information Name: NORTH MASON PEE WEES Mailing Address: 302 NE HAVEN LAKE DR City: TAHUYA State: WA Zip: 98588 Contact Number (253 )208-3235 Washington State Fireworks License Information (Copy Required) License No.: Date of 00506 Issue: 02/20/2014 ❑ Pyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: L�.Ga#-a.�c � .xstc.�► _ _ Insured: Certified Holder: � . Location of stand/display 123 oR Address: 40�@iFtNLF in9'£ 2412= NE HWY 3, BELFAIR, WA pAD b Directions to Site: pjjkL,pc �f2 �►.j _ IA c yr�,p Ar Parcel Number: Legal Description: Legal Property Owner: * * Please see the reverse side to complete your application FIRE PROTECTION BUREAU FIREWORKS LICENSING PROGRAM PO Boa 42600 Olympia WA 98504-2600 (360)596-3914 FAX: (360)596-3934 APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWM6512 TO Governing body of city,town,or county in which DATE OF 02/2014 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 RAYMOND MOW 2120 MILWAUKEE WAY, TACOMA, WA 98421 Location of proposed fireworks stand[Enclose drawing of stand location] VACANT LOT 24121 NE HWY 3 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 --- ----- ---- ---- -- -- - -- -- - - - -- ---- -- - - -- - -- - -- - -- - --- - ---- -- ---- --- FIREWO:D.KS STAND PERMIT For the Fireworks Sales Year of: 2014 (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 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 4te Sales for December 31st From: From: To: To: Sponsor NORTH MASON PEE WEES Location W*F-Abf fn8;- -;1++ NE HWY 3, BELFAIR, WA RO-W3. LO /s/ /s/ ems Jt f0 FOR RAYMOND MOW Signature of Official Granting Permit Signature 4Applicant Title Agency Date Pen-nit Number Licensee Name NORTH MASON PE WEES License Number 00506 3000-420-013 (R 3/D9) Washington State Patrol �W� ��,,..�, Fire Protection Bureau 15993 Office Of The State Fire Marshal Washington State Fireworks Lic Fireworks Stand License �nsc Licensee Information License is Non-Transferable and Valid for Only One Stand North Mason Pee Wees 2120 Milwaukee Way Tacoma, WA 98421 State F' e rs a z License Number: WSPFL-00506 , h etac t is wa e c rry with you for Stand Information verification o cert cation. Contact Person: Raymond Mow Washington State Patrol Fire Protection Bureau 15993 Phone Number: (253) 208-3235 Office Of The State Fire Marshal County: Mason Date of Expiration Date of Issue ANNUAL FIREW R STAND LICENSE Stand Number: SN-08436 Licensee: N 1vl:torie Wees January 31, 2015 February 20, 2014 Contact Person: License Number: ym°nd Maw.k Stand Number: 1U8� l 'alid For One Stand] Stand Location: Z� (> Date of Expiration. J ti 3 Location: 1 (Stand Location To Be Completed B L tan ation To icensee] `"� x S e Completed By Licensee] 3000-420-012(R 9/05) State Fire arsh g ture Licensee Signature AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/VYVY) �� I l/l/2014 10/31/2013 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). PRODUCER Lockton Companies,LLC NAMEACT 3280 Peachtree Road NE,Suite#250 PHONE FAx AIC No): Atlanta GA 30305 E-MAIL (404)460-3600 ADDRESS: INSURERS AFFORDING COVERAGE NAIC# INSURER A:Everest Indemnity Insurance Company 10851 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 COVERAGES CERTIFICATE NUMBER: 12219627 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 LTR INSR WVD POLICY NUMBER MMIDD/YYYY MM/DO/YYYY LIMITS A GENERAL LIABILITY N N S18GL00242-131 ll/l/2013 Il/l/2014 EACH DAMAGE TO RENTED X OMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 300,000 CLAIMS-MADE 1XIOCCUR MED EXP(Any oneperson) PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2-000-000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2 000.000 POLICY PRO JECT X LOC $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMI I Eaccident) $ X X } ANY AUTO Y(Per person) $ XXALL OWNED SCHEDULED Y Per accident $ XXXXXXX AUTOS AUTOS $ XXXXXXX NON-OWNED MAGE HIRED AUTOS AUTOS $ XXXXXXX UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX EXCESS LIAR HCLAIMS-MADE AGGREGATE $ XXXXXXX DED I I RETENTION$ $ XXXXXXX WORKERS COMPENSATION NOT APPLICABLE AND EMPLOYERS'LIABILITY Y/N TORY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? ❑ N/A $ XXXXXXX (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ XXXXXXX If DEes,describe under SCRIPTION 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) Reid Realty located at 23861 NE Hwy 3 in Belfair,Wa(Loc.WWM6512)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. 12219627 AUTHORIZED REPRESENTATIVE North Mason Pee Wees Maser on COu ty PO BOX 186 426 W Cedar Shelton WA 98584 l r ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD © 1313- 10 CORD CORP TION.All rights reserved 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 designated 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 • Desigpated landin area 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 'ntai ed. Signed Date g5;•Z3 FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: a - 6 t t •� � R • .fie y -:-. '`j i Y r k � • LU 471 .rx. ` ►•"R' =, _ �.� r� r Y��mot. _ -�j:,_a _ . _ I � •