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HomeMy WebLinkAboutFIR2008-00028 Fireworks - FIR Permit / Conditions - 5/20/2008 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262 Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext.352 Shelton, WA 98584 i� FIRE PROTECTION PERMIT FIR2008-00028 APPLICANT: ROBERT SUMARA RECEIVED: 4/22/2008 CONTRACTOR: LICENSE: EXP: ISSUED: 5/20/2008 SITE ADDRESS: 23331 NE STATE ROUTE 3 BELFAIR EXPIRES: 11/20/2008 PARCEL NUMBER: 123325000014 LEGAL DESCRIPTION: SAM B. THELER'S HOME & GAR TRS TR 6 S 1/2 OF PROJECT DESCRIPTION: FIREWORKS STAND GENERAL INFORMATION System Information Type of Use: COMM 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 SpdnkleR: 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 FIR2008-00028 Please refer to the following pages for conditions of this permit. 1 of 4 CASE NOTES FIR2008-00028 CONDITIONS FOR FIR2008-00028 1.) Site shall meet minimum requirements of the Mason County Standards for the Operation of Retail Fireworks Stands (see attached). X Inspection by the Fire Marshal required prior to opening. X, �L� This permit becomes null and void if work orconstruction 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 orthe 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:/ u�uzlL, � �il�c DATE: h� FIR2008-00028 Please refer to the following pages for conditions of this permit. 2 of 4 MR. Mason County HE Nam=4SWq! Fireworks Permit Application PO BOX 186 Permit# FIR':�'1)60�= OUyo�� RE 426 W Cedar St Shelton WA 98584 Receipt # SJ ��7 ,o8 (360) 427-9670 ext 273 �3 MASON C;OUN7ry CK # OAS Date Received d d 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: 'T ,Q Mailing Address. Z>. City: Adc-1190 State: ,C} Zip: Contact Number Sponsor Information Name: Mailing Address: f City: iyA— State: Zip: Contact Number �s; ) Washington State Fireworks License Information (Copy Required) License No.: Date of 4,P41— _7)reV,?j _ _ Issue: f44-,r ❑ 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: Directions to Site: �y Parcel Number: ,6—LZ 1_1,S_ Z;, Legal Description: Legal Property Owner: " _ AA CATS * * Please see the reverse side to complete yotir a�11ication � AMA dili!Sc;•cir^k•'> _. ��'�'•�F Y trs�. i 'ni.f•Cw, 1/f,Jrn %'�"Ir ict r} `k i- rR rrbt pa+:i.A Tul. br. , :. i,rT t>, 7TIs7[ .K•N°5.. The f6flowing 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 0 Private Roads and Right of Ways • Trees/Brush • Landmarks • Utilities and Gas • Mortar separation distance • Desi ated 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 maintained. Signed J� i �� ✓ Date FOR OFFICIAL USE ONLY BELOW THIS LINE Accepted By: Date: ACO.RO. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYV) 3 '28 2008 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 INSURERA:Lexington Insurance C Thunder Fireworks, Inc. INSURER B:Granite tat Insurance 09 5207 187th Street East Tacoma WA 98446 INSURERc:Roval & Sun & Alliance Ins Co INSURERD:AXis Surplus Ins Company 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 ADWL POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER LIMITS A GENERAL LIABILITY 6990331 11/15/2007 11/15/2008 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGES RENTED PREMISES Ea accurence $5 O 0 0 CLAIMS MADE Fx-]OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $1,000,000 GENERALAGGREGATE $2 ,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:' PRODUCTS-COMP/OP AGG $2,000,000 POLICY 7 PRO LOC B AUTOMOBILE LIABILITY CA93829656 11/15/2007 11/15/2008 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1, 000, 000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC $ AUTO ONLY: AGG $ D EXCESSIUMBRELLA LIABILITY EAU710 6 5 0 11/15/2007 11/15/2008 EACH OCCURRENCE $9,000,000 X I OCCUR CLAIMS MADE AGGREGATE $9,000,000 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE S Ryes,describe under SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT $ C OTHER M071124 11/15/2007 11/15/2008 LIMIT $500,000 B Transit Cargo - $1000 ded CA93829655 11/15/2007 11/15/2008 IMIT $1,000,000 Trailer Interchange DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS OCATION: HOOD CANAL MASONIC CENTER 23341 NE STATE ROUTE 3 BEL FAIR WA 98528 DDITIONAL INSURED: MASON COUNTY AND ALL IT'S EMPLOYEES, ROBERT SUMARA, LEE ISOM, HOOD CANAL MASONIC CENTER. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED MASON COUNTY BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE P.O BOX J CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHELTON WA 98581 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE nnD ACORD 25(2001/08) ©ACORD CORPORATION 1988 C� I i Washington State Patrol 8920 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 Robert S. Sumara Post Office Box 417 f Allyn, WA 98524 License Number: WSPFL-00448 State Fire Marshal Signa ure Detach this wallet card and carry with you for verification of certification. Stand Information - Washington State Patrol 8 n Q Contact Person: Robert Sumara Fire Protection Bureau 7 Phone Number: (360) 427-1087 Office Of The State Fire Marshal ANNUAL FIREWORKS STAND LICENSE County: Mason Date of Expiration Date of Issue Licensee: Robert S.Sumara Stand Number: SN-03243 January 31, 2009 April 1, 2008 Contact Person: Robert Sumara License Number: WSPFL-00448 Stand Number: SN-03243 [Valid For One Stand] Date of Expiration: January 31,2009 Stand Location: Location: s Stand Loc ti.R To e Completed By Licensee] [Stand Location To Be Completed By Licensee] State Fire Ma hal Signature Licensee Signature