HomeMy WebLinkAboutFIR2015-00030 Fireworks Stand - FIR Permit / Conditions - 10/24/2014 oCo MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line (360)427-7262
Phone: (360)427-9670, ext. 352
Mason County Bldg. III
426 W. Cedar St
Shelton, WA 98584
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1834 FIRE PROTECTION PERMIT
FIR2015-00030
APPLICANT: NEW LIFE ON THE PENINSULA
CONTRACTOR: LICENSE: EXP:
RECEIVED: 6/10/2015
SITE ADDRESS: 23771 NE STATE ROUTE 3 BELFAIR ISSUED: 6/22/2015
PARCEL NUMBER: 123294100120 EXPIRES: 12/22/2015
LEGAL DESCRIPTION: TR 12 OF NE SE EX N 100'
PROJECT DESCRIPTION: FIREWORKS STAND LOCATED ON A VACANT LOT: 23771 NE SR 3 - BELFAIR, WA
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?:
Dry Chemical?: Pressure Switches:: Smoke Detectors: Duct Detectors:
Wet Chemical?: Zones: Heat Detectors:
Sprinkler?:
Standpipe?: 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
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FIR2015-00030 Please refer to the following pages for conditions of this permit. Page 1 of 7
CASE NOTES
FIR2015-00030
CONDITIONS FOR
FIR2015-00030
FIR2015-00030 Please refer to the following pages for conditions of this permit. Page 2 of 7
1.) Owner/Age sponsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
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FIR2015-00030 Please refer to the following pages for conditions of this permit page 3 of 7
2.) Sales:
WAC 212-17-21505 Retailers of fireworks-General provisions.
Fireworks may be sold from 12.00 noon to 11:00 PM on June 28 through 9:00 PM on July 5. Fireworks may not be sold between the hours of 11:00 PM
and 9:00 AM fr June 28 through July 3. Fireworks may not be sold from 12:00 midnight to July 4 through 9:00 AM on July 5.
X
X reworks may Id from 12:00 noon to 11,00 PM on each day from the 27th of December through the 31st of December of each year.
Only Division 1 AG consumer fireworks,obtained from state-licensed wholesalers, not otherwise prohibited by chapter 70.77 RCW or local ordinance, and
holiday related products incidental but related to these products, may be sold in retail fireworks stands.
X
Fireworks stand locations:
WAC 212-17-21509 Retailers of fireworks-location.
(1)Activities or uses subject to this rule shall not be limited in location except where such activities or uses are prohibited or controlled by local
development regulation,traffic safety or road construction standards.
(2)Temporary retail fireworks stands shall not be located more than 150 feet,from a private way,fire department access road,public road,street or
highway as measured by an approved route around the exterior of the stand:The minimum requirements for private way shall be determined by the local
authority having jurisdiction,but shall not exceed the requirements of locally adopted street,road and access standards. (3)Any two
retail fireworks stands shall be at least 100 feet apart or shall be separated by a road,street or highway not less than 30 feet In width.
(4) Retail fireworks stands shall be located as required by table 212-17-21509 in this section and attached to the permit.The minimum required area
surrounding the stand shall be marked or flagged,except that flagging and marking shall not block a sidewalk or pedestrian pathway. Flagging need not
exceed twenty feet in any direction.
(5)Retail fireworks stands shall not be located closer than 100 feet from any motor fuel dispensing station,retail propane dispensing station,flammable
liquid storage, or combnustible liquid storage.Retail fireworks stands shall not be located closer than 300 feet from any bulk storage of flammable or
combustible liquid-or gas,including bulk plant dispensing areas.
X
Surrounding area arond fireworks stands:
WAC212-17-21511 Retailers of fireworks-areas around the retail fireworks stand.
(1)The minimum areas around the retail fireworks stand specified in WAC212-17-21509 shall be kept free of accumulation of dry grass,dry brush and _
combustible debris. No parking shall be permitted within this minimum area.
.(2)No motor vehicle or trailer my be parked within twenty feet of a retail fireworks stand except when delivering, loading or unloading fireworks.
(3)Fireworks shall not be discharged within 100 feet of a retail fireworks stand. Signs reading"NO FIREWORKS DISCHARGE WITHIN 100 FEET"in %
letters at least 2 inches high,with the principal stroke of not less than one half inch,on contrasting background„shall be conspicuously posted on all four
sides of the stand.
(4) No smoking shall be allowed within the retail fireworks stand or within the minimum flagged off area.Signs reading"NO SMOKING WITHIN 20 FEET'
in letters at least 2 inches high,with the principal stroke of not less than one half inch, on a contrasting background, shall be conspicuously posted on all
four sides of the stand.
X
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Electrical supply and usage:
WAC 212-17-21513 Retailers of fireworks stand use and construction.
(1)Fireworks may be sold from:
(a)A permanent structure which meets provisions of WAC 212-17-21505(3).
(b)Temporary,stable structures made of wood, metal,fiberglass or other material.Any temporary fireworks retail stand greater than 400 square feet
shall meet the requirments of a permanent structure,except tents or canopies as defined in the international Fire code retail stand greater than 400
FiR201 5-00030 Please refer to the following pages for condltions of this permit. Page 4 of 7
square feet shall meet the requirements of a permanent structure.
(c)Tents,canopies,or structures utilizing temporary membrane material.Ali tents,canopies or temporary membrane materials structures shall be made
from fire retardant material or treated with fire retardant as identified in the International Fire code.Any tent,canopy or temporary membrane material
structure falling within the scope of the International Fire code shall comply with those requirements.When those requirements are in conflict with other
provisions of these rules,the more restrictive provisions shall apply.
(2)Battery powered equipment,electrical equipment cords which are used in conjunction with a retail fireworks stand or a temporary storage structure or
location must be listed by a recognized laboratory and used in accordance with that listing.If electrical power is supplied by an extension cord,the size of
the cord, the length of the cord and the amperage'and the voltage supplied shall be in compliance with the requirements of the National Electrical code, _
current edition.The cord shall be protected as necessary from drive-over and other physical damage. No additional permits from a city or county or state
official having jurisdiction shall be required for these temporary uses except As specified in subsection(5)of this section.
(3)All heating units shall be listed by a recognized testing laboratory and shall be used in accordance with the listing_Heating sources shall have"tip over"
and temperature overheat protection.All heating devices shall have sealed type elements(Le,oil filled or water filled radiator type).Open flame heating
devices are prohibited. x.
(4)Generators which use combustible fuel and which are at least twenty feet•from the retail fireworks stand or the temporary fireworks storage structure
shall be allowed.Generator fuel shall be limited to not more than five gallons and stored at least twenty feet from all stands.
(5)Compliance with the National Electrical code,current edition,shall be required for all new, permanent electrical installations,including temporary
power drops, subject to possible fees.
(6)Retail sales of fireworks and other products which are holiday related shall be from buildings used for no other purpose.
X7
Storage associated with retail fireworks:
WAC212-17-21517 Retailers of fireworks-Temporary fireworks storage associated with the retail fireworks stand
operation.
(1)Temporary fireworks storage is not permanent fireworks storage.Temporary fireworks is defined as storage associated with retail fireworks sales and
may only be from June 13 through July 13 and from December 12 through January 10 of the following year.Permanent fireworks storage is associated
with retail or wholesale fireworks activites when the period of time of storage'.is other than,or longer than that specified for temporary storage.Temporary
fireworks storage shall be in accordance with this section.Permanent fireworks storage is subject to the intemaitonal Fire Code and the local ordinances.
(2)Delivery of fireworks to a location,or storage of fireworks in a facility, not authorized by the license and permit is prohibited. If the approved storage
location is outside the jurisdiction issuing the permit, the authority issuing the permit shall notify the appropriate authorities of the jurisdiction in which the
storage is to be Icoated.
(3)A temporary fireworks storage facitlity or a temporary fireworks storage location shall be authorized as a part of a license and permit if it meets the
requirements specified herein.
(4)No open flames nor any type of open flame equipment shall be allowed in any temporary fireworks storage structure.
(5)Storage of fireworks authorized by a retail license and permit is legel only'during the periods specified in this section.
(6)Fireworks may be stored:
(a) In a locked or secured retail fireworks stand;or
(b)In a locked or secured truck,container,trailer,other vehicle or anything similar which is not less than 20 feet from the retail fireworks stand during
hours of retail sales;or
(c)Ina locked or secured truck,container,trailer,other vehicle or anything similar which is not less than 20 feet from an inhabited building where the
term"inhabited building" is defined as in the Intemational Fire Code;or
(d)In a magazine which meets the minimum standards of a type 4 as prescribed by the international Fire code,and which is not less than 10 feet from
an inhabited building where inhabited building"is defined as in the International Fire code: or
(e)In a locked or secured metal or wooden garage,shed,barn or other accessory building,or anything similar which is not less than:20 feet from an
inhabited building for storage of fireworks for one or two retail stands;or 30 feet from an inhabited building for storage of fireworks for three or more
stands. ti
The term"inhabited building Is defined as in the International Fire code.
(7)The local authority having juisdiction may reduce the minimum separation required of this section provided that safety of life and property is not
diminished. i
IR2015-00030 Please refer to the following pages for conditions of this permit. Page 5 of 7
(8)No Cooking is permitted in a retail fireworks stand or in a temporary fireworks storage structure.
(9)Temporary fireworks storage structures may be inspected prior to use and other inspections may occur on other days as warranted.There shall be no
additional chalr? for all such inspections.
X
3.) Valid Permit Myst be on-site.
X
4.) 1.)must conform to IFC Chapter 24.
2.)WAC documents provided must remain on site. s
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.
Signature a Date
OWNER - RESENTATI - CONTRACTOR
Print Name o tndreate>
a
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FIR2015-00030 Please refer to the following pages for conditions of this permit. Page 6 of 7
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FIREWORKS LICENSING PROGRAM
PO Box 42600
Olympia WA 98504-2600
'wwne (360)596-3914 FAX: (360)596-3934 m
APPLICATION
FOR RETAIL FIREWORKS STAND PERMIT VWVf6554
TO Governing body of city,town, or county in which DATE OF ,� g, 2015
fireworks stand will be located. APPLICATION
Applicant Name Address,City,State
NEW LIFE ON THE PENINSULA 2120 MILWAUKEE WAY,TACOMA,WA.98421
Sponsor(If other than applicant) Address,City,State
TYLER LUKKASSON 2120 MILWAUKEE WAY,TACOMA,WA 98421
Location of proposed fireworks stand lEnclose drawing of stand location]
23771 NE SR 3, BELFAIR, WA VACANT LOT TOESEPLAN. ;RUST'SE
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Manner and place of storage prior,during,and after sales dates � 101$,P CTION.
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: 2015
(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. 03361.4G Consumer fireworks at the location
designated herein between the following date and times:
Sales for July 4th Sales f8 D ember 31"
From: /From:
To: To: `
N. .
S onsor TYLER LUKKASSON-. ' '
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1NT�LOT, _2377 p3�, BELFAIR, WA
LOCatlOn,.•:VA(l
FOR TYLER LUKKASSON
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3000.420-013 (R3/09) P,F`i`. .�,•
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A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
11/1/2015 r 6/8/2015
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).
CO
PRODUCER Lock-ton Companies NAME:NTACT
3280 Peachtree Road NE,Suite#250 PHONE FAX
Exf: (A/C,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
COVERA39T6134 CERTIFICATE NUMBER: 13523650 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 SUER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY N N SI8GL00242-141 11/l/2014 11/l/2015 EACH OCCURRENCE
DAMAGE TO_7 RENED CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ 500,000
MED EXP(Any oneperson) $ 5,000
PERSONAL&ADV INJURY s 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.00 000
POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY NOT APPLICABLE (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 AUTOSer
$ XXXXXXX
UMBRELLA LIAB OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXXX
EXCESS LIAR HCLAIMS-MADE AGGREGATE $ XXXXXXX
DED RETENTION$ $ XXXXXXX
WORKERS COMPENSATION NOT APPLICABLEPER
AND EMPLOYERS'LIABILITY Y/N STATUTE 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 as,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ XXXXXXX
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required)
Property located at Vacant Lot,23771 NE SR 3,Belfair,WA(WWT6554). 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
13523650
Mason County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
New Life on the Peninsula THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO Box 186 ACCORDANCE WITH THE POLICY PROVISIONS.
426 W.Cedar
Shelton WA 98584 AUTHORIZED REPRESENTMVE
0198E-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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I CAI -I I. n
A'a), 21, 201
Re: NEW LIFE YOUTH FIREWORKS
To: 'Maom it may eoncem.
Above; stawd has my? penniss on to use Elie laropen~ locaLed w 23771 NF: SR 3, Belfair Wa, for ft u:
of retailing fire words and related products beginning. June 26, 2015 t1m)ugh July 5p 2015.
Accordingi
Edward Fish
FIRE p
HARSH
MASON COUNTY (360)427-9670�hhelton ext.352
tY I
DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext. 352
BUILDING• PLANNING, FIRE MARSHAL (360)482-5269 Elma ext. 352
Mason County Bldg. III, 426 West Cedar Street
PO Box 279, Shelton, WA 98584 www.co.mason.wa.us
STANDARDS FOR THE OPERATION OF RETAIL FIREWORKS STANDS
SALES:
WAC 212-17-21505 Retailers of fireworks—General provisions.
• Fireworks may be sold from 12:00 noon to 11:00 p.m. on June 28 through 9:00 p.m. on July 5.
Fireworks may not be sold between the hours of 11:00 p.m. and 9:00 a.m. from June 28 through July
3. Fireworks may not be sold from 12:00 midnight on July 4 through 9:00 a.m. on July 5.
Fireworks may be sold from 12:00 noon to 11:00 p.m. on each day from the 27th of December
through the 31 st of December of each year.
Licensees shall familiarize all persons working in a retail fireworks stand with the provisions of these
rules.
Failure to comply at any time with the provisions of this rule or any other applicable regulation shall
constitute a violation of chapter 70.77 RCW and may result in the temporary suspension or
immediate revocation of the license or permit, closure of the fireworks sales or storage structure, the
seizure and/or forfeiture of some or all of the fireworks, and other criminal penalties as specified by
law.
APPROVED FIREWORKS:
• Only Division 1.4G consumer fireworks, obtained from state-licensed wholesalers,not otherwise
prohibited by chapter 70.77 RCW or local ordinance, and holiday related products incidental but
related to these products,may be sold in retail fireworks stands.
FIREWORKS STAND LOCATIONS:
WAC 212-17-21509 Retailers of fireworks-Location.
(1)Activities or uses subject to this rule shall not be limited in location except where such activities
or uses are prohibited or controlled by local development regulation, traffic safety or road
construction standards.
(2)Temporary retail fireworks stands shall not be located more than one hundred fifty feet from a
private way, fire department access road,public road, street or highway as measured by an
approved route around the exterior of the stand. The minimum requirements for a private way
shall be determined by the local authority having jurisdiction,but shall not exceed the
requirements of locally adopted street, road and access standards.
• (3)Any two retail fireworks stands shall be at least one hundred feet apart or shall be separated by a
road, street or highway not less than thirty feet in width.
(4)Retail fireworks stands shall be located as required by Table 212-17-21509 in thFIREThe
minimum required area surrounding the stand shall be marked or flagged, eft66
and marking shall not block a sidewalk or pedestrian pathway. Flagging n A
feet in any direction.
Retail Fireworks Stands-Minimum Clearances
MOTOR MOTOR
VEHICLE VEHICLE
TRAFFIC TRAFFIC
Combustibl Property Parkin PUBLIC PRIVATE
Buildings es Line g ROAD* ROAD*
BACK OF STAND 20 FT. 20 FT. 5 FT. 20 20 FT. 5 FT.
FT.
SIDE OF STAND 20 FT. 20 FT. 5 FT. 20 20 FT. 5 FT.
FT.
FRONT OF STAND 40 FT. 40 FT. 20 FT. 20 20 FT. 20 FT.
FT.
20 FT.** 20 FT.**
NOTE:
Clearance distances are not cumulative
*Measured from the outer edge of the nearest traffic lane.
**If stand is equipped with 135 fusible links which will automatically close all sales doors in case of fire,or is equipped with a wire-mesh screen with openings
of not more than one inch which covers not less than 90%of all sales openings.
(5)Retail fireworks stands shall not be located closer than one hundred feet from any motor vehicle
dispensing station,retail propane dispensing station, flammable liquid storage, or combustible
liquid storage. Retail fireworks stands shall not be located closer than three hundred feet from any
bulls storage of flammable or combustible liquid or gas, including bulk plant dispensing areas.
EXCEPTION:
1.Fuel for generators as allowed by WAC 212-17-21513(4).
2.Fuel within the tanks of motor vehicles.
SURROUNDING AREA AROUND FIREWORKS STANDS:
WAC 212-17-21511 Retailers of fireworks-Area around the retail firework stand.
(1) The minimum areas around the retail fireworks stand specified in WAC 212-17-21509 shall be kept free
of accumulation of dry grass, dry brush and combustible debris.No parking shall be permitted within this
minimum area.
(2)No motor vehicle or trailer may be parked within twenty feet of a retail fireworks stand except when
delivering, loading or unloading fireworks.
(3)Fireworks shall not be discharged within one hundred feet of a retail fireworks stand. Signs reading "NO
FIREWORKS DISCHARGE WITHIN 100 FEET" in letters at least two inches high,with a principal stroke of not less
aPOo MASON COUNTY (360)427-9670 Shelton ext.352
DEPARTMENT OF COMMUNITY DEVELOPMENT (360)275-4467 Belfair ext. 352
BUILDING. PLANNING• FIRE MARSHAL (360)482-5269 Elma ext. 352
Mason County Bldg. III, 426 West Cedar Street
1854 PO Box 279, Shelton, WA 98584 www.co.mason.wa.us
FIR20 S - 0
Mason County Fireworks Permit Application
Incomplete applications will not be accepted
A permit for 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:
Owner: NEW LIFE ON THE PENINSULA
Mailing Address: 50 NE GARRICK LANE City. BELFAIR State: WA Zip: 98528
Phone#: 360-801-5403 Email: LicensingNQtntfireworks.com
Sponsor Information:
Name: TYLER LUKKASON
Address: 50 NE GARRICK LANE City: BELFAIR State: WA Zip: 98528
Phone#: 360-801-5403 Email:LicensingN@tntfireworks.com
Washington State Fireworks License Information (Copy Required):
License Number: 15-0 5q a Date of Issuance t 0,y"dVj Iai Qpt!�;
❑ Pyrotechnic Operator License ® Fireworks Stand License
Bond or Certificate of Insurance (Copy of Certificate/Bond Required):
Provider: SEE ATTACHED
Insured:
Certified Holder:
Location of Stand/Display:
Site Address:VACANT LOT, 23771 NE Sk 3, BELFAIR, WA
Directions to Site:
Parcel Number: (twelve digit number)12 3Z61 -j GD 120
Legal Property Owner
"Please see reverse side to complete your application"
RECEIVED
JUG! 10 2015
426 W. CEDAR ST.
�'S�NGTGHSTgT� Washington State Patrol Fire Protection Bureau
FIRE
Office of the State Fire Marshal
ARSHALNSUMER FIREWORKS RETAIL SALES STAND LICENSE 15-0592
RSXAVSGF`4 Stand Number: SN-09678
Licensee Data Operational Data
American Promotional Events, Inc. Wholesaler: TNT Fireworks
2120 Milwaukee Way County of Operation: Mason
Tacoma, WA 98421 Operates For:
New Life on the Peninsula
License Number: WSPFL-02766
Stand Operated By: Tyler Lukkasson
Phone Number: (253) 922-0800
Date of Issue:March 18, 2015 Date of Expiration:January 31, 2016
Consumer Fireworks Retail Sales Stand Licenses issued after May are ONLY valid for New Years Sales
This license is NOT valid without a permit from a local fire code official/authority having jurisdiction. This license allows for operation of a single location/stand for
retail sales to the public of state legal consumer fireworks purchased only from a licensed fireworks wholesaler.
THIS LICENSE PORTION ACCOMPANIES YOUR LOCAL PERMIT APPLICATION
i APPROVED
MA S C FIRE RSHAL
BY
SUBJE T FIELD INSP TIpN
ALL APPLICASL CODES SHALL APPLY. ERRORS
AND/OR OMISSIONS ON PLANS ARE SOLE RE—
SPONSIBILITY OF OWNEWCONTRACTOR. CORREC—
TIONS REQUIRED FROM FIELD INSPECTION' SK-SLI
BE AT OWNER/CONTRACTOR'S EXPENSE. THIS /,C
'PROVygAL DOES NOT GRANT TO ANY PEAI�04 T
NITOWNE INSIk 1WITPY c9tfi�SIT,�T i ! •
REORDER 905•U.S.PATENT NO.5538290,5575508,6641183,5785353,5984364,6030000
V.
GL Cost Center: 41120
AMERICAN PROMOTIONAL EVENTS
® NORTHWEST Check No. — 30037245
dba TNT Fireworks
PO BOX1318 Check Date — 5/7/2015
4511 Helton Drive Industrial Park
i Florence,AL 35630 Stub 1 of 1
INVOICE • DESCRIPTION '• • •
4 r 6552/424/J15/499 5/4/2015 OPERATION FEE*** 100.00 100.00
wwrO554
100.00 100.00