HomeMy WebLinkAboutFIR2011-00052 Final Fireworks Stand - FIR Permit / Conditions - 12/27/2011 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
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FIRE PROTECTION PERMIT FIR2011-00052
APPLICANT: JOHN MILLER RECEIVED: 12/19/2011
CONTRACTOR: LICENSE: EXP: ISSUED: 12/20/2011
SITE ADDRESS: 22950 NE STATE ROUTE 3 BELFAIR EXPIRES: 6/20/2012
PARCEL NUMBER: 123325000044
LEGAL DESCRIPTION: SAM B. THELER'S HOME & GAR TRS TR 19-B
PROJECT DESCRIPTION: FIREWORKS STAND
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?: 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?:N Third Floor;:
Total: $100.00 $100.00
FIR2011-00052 Please refer to the following pages for conditions of this permit. Page 1 of 6
1.) Owner/Agent is responsible to post the assigned address and/or purchase and post private road signs in accordance with Mason County Title 14.28.
X
2.) Valid Permit Must be on-site.
` X
FI R2011-00052 Please refer to the following pages for conditions of this permit. Page 3 of 6
3.) Consumer fire works may be sold only on the following 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 9 AM to 12 noon
X
Only Washington State Fire Marshal approved class C common fire works may be sold.
X
Afire 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 marked and flagged.
X
Motor vehicles 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 in contrasting 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 colors 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 grade type 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 element heating devices are prohibited.
X
Generators shall be 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
Sleeping inside a fireworks stand is prohibited.
X
FIR2011-00052 Please refer to the following pages for conditions of this permit. Page 4 of 6
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.
X
There shall be a minimum of 2 approved 2 1/2 gallon pressurized water fire extinguishers located adjacent to each exit door.
X
Cooking, open flame 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
stand.
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 the public.
X
It 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. Driver's license or photo ID showing date of birth issued by a public or private school, state, federal or foreign government is acceptable.
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 above described property and structure for review and inspection.
OWNER OR AGENT: DATE:
FIR2011-00052 Please refer to the following pages for conditions of this permit. Page 5 of 6
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CONCRETE MECHANICAL MANUFACTURED HOME r
Date ♦3 y 0-
Footings !Setbacks Ribbons m
Gas Piping �
6 interior Date By interior•Date By Date By
O Exterio+r Date BY Exterior-Date_ B Set-up Q
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Point Load/isolated Footings INSULATION Date By Z
BG/SLAB INSULATION -
Date By Data By FIRE DEPARTMENT
Foundation Wails Floors Date By
Date By Data By DECKS
FRAMING walls Date By
Date By Data By PROPANE TANKS
PLUMBING Vault Date By
Date By OTHER
Groundwork Attic
Type.
Date BY Date_ By Date By
o.Vv.V DRYWALL Type:
Int.Brace Wall Date. By �
Date By Date 6y
FINAL INSPECTION N
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Date By Date By Dato By
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Type of Insp. Fail Date Date Done By Comments CA
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` 4 Mason County
Fireworks Permit Application -
PO BOX 186
426 W Cedar St Permit# FIR
Shelton WA 98584
(360) 427-9670 ext 273 Receipt #���� (� J
CK #
,AI04_
Date Received
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 Informatio
Name: �L
Mailing Address: I s 1 S� �It sf }}I TC (fgV�
City: ��a�c� State: I,,, Zip:
Contact Number ( ,o ) � _p t 7 .2�
Sponsor Information
Name: �, 'r� / c K-tS
Mailing Address: wH I TE Ce ,J Ze n
City: _.St�4� State: _W A-
Contact Number (��o ) z.o 19,; Z
Washington State Fireworks License Information (Copy Required)
License No.: Date of
Issue:
❑ Pyrotechnic Operator License fireworks Stand License
Bond or Certificate of Insurance
(Copy of Certificate/Bond Required)
Provider: A/1&7D! S �•JS"v rt,p► c-6-
Insured:
Certified Holder: 56
`may
Location of stand/display
Address: �—
Directions to Site.
A AC &QSTRQ T TO &
Parcel Number: �_2.SZS' _ o _ y
Legal Description:
Legal Property Owner.
* * Please see the revers
e 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
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 pe aining to the sales or discharge of fireworks
shall be maintai
Signed Date
FOR OFFICIAL USE ONLY BELOW THIS LINE
Accepted By: Date:
Washington State Patrol 1 2 6 1 5
Fire Protection�Bureau
Office Of The State Fire Marshal
ANNUAL FIREWORKS STAND LICENSE
Licensee: Boom nr ctions
Contact Person: Johrx` ille �,tr�
License Number: WIPFL-024, ,
Stand Number: R+06007' T id For One Stand]
Date of Expiration: J n ar
Location: 29�
tand Location om d see]
State Fire Mars i ature AV Licensee Signature
v
`" DATE IMMIDDlYYYY)
,4clpRo CERTIFICATE OF LIABILITY INSURANCE 5/117/2011
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 staternent on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACTNAME:
David Connolly Insurance Agency Inc. PHO WC.No FAX
9393 Bayshore Dr ADDRESS:
Silverdale,WA 98383 PRODUCER
CUSTOMER 1 0:
INSURERS AFFORDING COVERAGE NAIC•
INSURED INSURER A National Fire&Marine Ins-Company
Aurora Fireworks LLC INSURER B:
29399 Beach Dr NE INSURER C:
Poulsbo,WA 98370
INSURER D
INSURER E:
INSURER F.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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.
IRSR ADDLSURR TYPE OF INSURANCE POLICY NUMBER MtPhWIDrYYYY MMIDDIYYYYYY LIMITS
LTR
GENERAL LIABILITY X 72LPS-013925 5/1/2011 5/1/2012 EACH OCCURRENCE $ 1,000,000.00
rk
MERCIAL GENERAL LIABILITY P MI n S 100,000.00
ACLAIMS-MADE OCCUR MED EXP(Any one person) f 5,000.00
PERSONAL 6 ADV INJURY S 1,000,000.00
GENERAL AGGREGATE S 2,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG S 1,000,000.00
X POLICY PROT LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS
BODILY INJURY(Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE $
HIRED AUTOS (Per ant)
NON-OWNED AUTOS $
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S f
WORKERS COMPENSATION WC STATUORY • I OTH-
AND EMPLOYERS'LIABILITY YIN
PR
ANY PROPRIETORIPARTNERlEXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? ❑ N/A
(MandatoryOFFICER/M In NH)EMBER E.L.DISEASE•EA EMPLOYEE f
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Mason County and Boomtown Fireworks are listed as an additional insured.
CERTIFICATE HOLDER CANCELLATION
Joe Solif SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
25603 NE State Route 3 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Belfair,WA 98528 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number.The public reporting burden for this
collection of information is estimated at 12 minutes per
response,including the time for reviewing instructions and
completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this
collection of information,including suggestions for reducing
this burden,to:U.S.Citizenship and Immigration Services,
Regulatory Management Division, 11 I Massachusetts
Avenue,N.W.,3rd Floor,Suite 3008,Washington,DC
20529-22 10.OMB No. 1615-0047.Do not mail your
completed Form 1-9 to this address.
Form 1-9(Rev 08/07/09)Y Page 3
12/06/2011 11:45 FAX 360 779 4537 SKY PIX C�j001
Dec 02 11 02:15p Gordon Sound 3606921015 p,1
FIREWORKS LICENSE AGREEMENT
This agreement is made between Joe Solif: as licensor and Firework SugermaTkat as
licensee for the �,3id purpose of allowing retail sales of Consumer. Fireworks frorn the
following location:
co
22950 NE STATE ROUTE 3 BELEAIR
Parcel tax ID.#.12332500(3044
The licensor represents that it owns: or con-t-ots the use of the lot as listed above and
agrees to vrant licensee the right to operate; a retail f rewofk stand on the Premises.Rv the
period of Dec 23,2010 through Jan 4, 2012 for a license Fez cif*$300.00 or 100/o of'gross
sales_wl-katever is greater, due no later than Jan. 5"', 2012-
The licensee shrill pay all cost involved in the erection_ operation and maiAttem,ice of the
stand, and shall guar
amee that the premises shall be retuned to the original condition
Li:h:.r removal of the stand,
1"be 1 icensec A-ll provide. hahility insurance coverage and provide to the lice-mor, before
occupancy. The insurance-shall name the licensor as m additional insured, arid licensee
v ell hold the hceusor harmless from any claims arising b-om the maintenance or
operations of tihc structure.
The lie-ensee shalt pay for and obtain licenses aad permits required lit, law and post any-
perfo?lance bonds wlllch might be requir-4 The J icensee shall guarantee that the stand
is operated in a business like manner and adhere to all local state regulations.
If'the propert-, iS sukl. ingress/egress changed,or locaeiun impacted d-ue to construction
or the like. thm this license is stibjcct to ievocatlon and v,-fiind of: any payments made.
LICENSOR: LICENSEE: �
1
Joe So1if- ov%,Tler 1=irewnrk SupenTtarket Representative
Ph onr:: 3 60-44 I-4873 Phouo: 360.620.1732