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HomeMy WebLinkAboutFIR2005-00048 Fireworks - FIR Application - 8/4/2023 Mason County Fireworks Permit Application - �B PO BOX 186 426 W Cedar St Permit# FIR Shelton-WA 98584 Receipt RECEIVED (360) 427-9670 ext 273 CK # DEC 132005 Date Received MASON COUNTY 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: Dave Cooper Mailing Address: 2120 Milwaukee way City: Tacoma State: wA Zip: 98421 Contact Number (360 ) 373-9050 Sponsor Information / 232,T q I Odd?0 Name: Dave Cooper Mailing Address: 2190 Mi 1WA11kPP WAY City: Tacoma State: wA Zip: 98421 Contact Number (360 ) 373-9050 Washington State Fireworks License Information (copy Required) License No.: Date of 00212 Issue: Feb. 9th, 2005 ❑ Pyrotechnic Operator License ® Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required) Provider: Insured: Certified Holder: Location of stand/display Address: HWY 3 Ri-1 fni r wA Directions to Site: - Parcel Number: - - Legal Description: Legal Property Owner: uoT� o,, Fes, * * Please see the reverse side`to'co ete PP our application Y i 4835 Washington State Patrol Fire Protection Bureau Office Of The State Fire Marshal • • Fireworks Stand License Washington ', Fireworks License License Is Non-Transferable And Valid For One Stand Licensee Information Dave Cooper ['---- Post Office Box 1436 Date Of Issue: February 7, 2005 State Fire Marshal Detach this wallet card and carry with you for Tacoma, WA 98401- Expiration Date: January 31, 2006 verification of certification_ Stand Information Washington State Patrol 4835 Fire Protection Bureau Contact Person: Dave Cooper Office Of The State Fire Marshal ,Phone Number: (360) 373-9050 Counly Mtsap FIREWORK STAND LICENSE• (ValidForOneStand] Licensee: Dave Cgnper i. L'icense Number: WSPFL-00212 Stand Number: SN-0001104 Contact Person: Dav�-C Stand Number: SN OOijtA`>i" Ltiddber-WSPFL 00212 Exairation Date: Jant 3�1- .op Stand Location. Location: ':.m _ .ToB :aihcYpleted By ticrosee) [Stand Location To Be Completed By Licensee] 12/06/05 11:48 FAX 2538302930 AMERICAN PROMO U 002/002 FROM Cooper Family FAX NO. 3603739050 Dec. 02 2005 07:47RM P2 Wuj nl*-NL-1 STAND DIAGRAM ACCOUNT NAME: '� ORDINANCE OF: CHAIRMAN: BOND AMOUNT: EXPIRES ON: TELEPHONE: HOMEA20-?371- 7C-1 WORK SETSACKREQUIRED: CURD/WALK: GAS: STAND ADDAESS:.1z3 VtoI-- 9 OTHER: BLDG: STORE/SHOPPING CENTER: `' rEs STAND FACES DIRECTION OF: CITY AND STATE: A x� �= ' NOTES: CROSS STREETS: AND STAND SIZE: TYPE STAND CREW INFORMATION ADDTL MTR'L: J UP-CREW: STAND NOTES: DATE UP: DATE DOWN: DOWN CREW. GARBAGE REMOVAL: YES NO NORTH f I i i m CD 6 i i l TA SOUTH '- SND NO. To: Mason County -From:-Karen Gower TNT Fireworks Dave Cooper ran a stand for New Years the last two years on Crazy Eric's property. Due to the produce stand he is moving the stand to Reid Real Estate for New Years 2005. He will fax you a diagram as soon as he has it drawn. Thank you! If you need to contact Dave Cooper, his cell #is 360-340-1931 APPLICATION FOR RETAIL FIREWORKS STAND PERMIT WWM5602 TO: Governing body of city, town, or county in which DATE OF 11/3/2005 fireworks stand will be located. APPLICATION: Applicant Name (Licensee): Address, City, State: RAVE COOPER- ----- --- - - -21-20-MILWAUKEE WAY, TACOMA,_WA 9&4_21---------- — Contact Person (If other than applicant): Address, City, State: DAVE COOPER 2120 MILWAUKEE WAY, TACOMA, WA 98421 Location of proposed fireworks stand: [Enclose drawing of stand location] HWY3 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 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - F ISTAND PERMIT REWORKS 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 MASON COUNTY local governing authority, the named person, firm or organization is hereby authorized to sell.U.N. 0336 1 AG Consumer fireworks at the location designated herein between the following date and times: h Sales For July 4 t Sales For December 31st From: From: �� -a�-.b J&Da To: To: 1 a - 31 - oS Sponsor: DAVE COOPER Locatio HWY 3 /s /s/ For DAVE COOPER S' n tune of Official ting Permit Signature of Applicant Title: FA(T Af,-6�66*L Agency: 1Zt4-3o-A0 Date: )a-QA-Q--S Permit Number: 6A aDb5 060118 Licensee Name: DAVE COOPER License Number: 00212 ACORD, CERTIFICATE OF INSURANCE ISSUE DATE11/17/2005 PRODUCER This certificate is issued as a matter of information only and confers no rights MCGRIFF,SEIBELS&WILLIAMS, INC. upon the Certificate Holder. This Certificate does not amend,extend or alter the coverage afforded by the policies below. . . ._PA. Box-10265----- - - --_ -- -- -- - - ------------- --- -- -- --- Birmingham,AL 35202 COMPANIES AFFORDING COVERAGE 205-252-9871 Company Crum&Forster Insurance Company A INSURED Company .American Promotional Events, Inc. B d/b/a TNT Fireworks Company P.O.Box 1318 C Florence,AL 35631 Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement,term or condition of 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,conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE LIMITS OF LIABILITY LT EXPIRATION A GENERAL LIABILITY GL0090947 11/01/2005 EACH OCCURRENCE $ 1,000,000 ®Commercial General Liability 11/01/2006 FIRE DAMAGE $ 100,000 ❑Claims Made®Occurrence MEDICAL EXPENSE EXCLUDED ❑Owners'and Contractors'Protection ❑x SIR:50,000 PERS.AND ADVERTISING INJURY $ 1,000,000 ❑ GENERAL AGGREGATE $ 2,000,000 General Aggregate Limit applies per: PRODUCTS AND COMP.OPER.AGG. $ 2,000,000 ©Policy❑Project❑Location AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT El Any Automobile BODILY INJURY(Per person) ❑All Owned Automobiles BODILY INJURY(Per accident) ❑Scheduled Automobiles ❑Hired Automobiles PROPERTY DAMAGE(Per accident) ❑Non-owned Automobiles COMPREHENSIVE ❑ COLLISION WORKERS'COMPENSATION WC Statutory Limit Other AND EMPLOYERS'LIABILITY EL EACH ACCIDENT EL DISEASE(Each employee) EL DISEASE(Policy Limit EXCESS LIABILITY EACH OCCURRENCE ❑Occurrence[]Claims Made AGGREGATE Re: Crazy Erics; Crazy Erics;Dave Cooper(4826 SE Sleepy Holly Court in Pt.Orchard,WA 98366);and Mason County(426 W Cedar Street in Shelton,WA 98584)are named as Additional Insured with respect to General Liability as required by written contract subject to policy terms,conditions,and exclusions. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT A FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ISSUER,COMPANY,ITS AGENTS OR REPRESENTATIVES. Crazy Erics Authorized Representative Dave Cooper Mason County Highway 3 _ Belfair,WA 98528 Certificate ID: SIK7GHV6