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HomeMy WebLinkAboutFIR2024-00040 Fireworks - FIR Inspections - 11/29/2024 INSPECTION CARD Mason County ' 615 W. Alder St. Building 8, Shelton, WA 98584 360-427-9670 ext 352 www.masoncountywa.gov PERMIT# FIR2024-00040 PROJECT ADDRESS 10 E ALDERBROOK DR UNION, WA 98592 PARCEL# 322335000014 PROJECT DESCRIPTION FIREWORK DISPLAY-ALDERBROOK OWNER ALDERBROOK RESORT&SPA ADDRESS 10 East Alderbrook Drive PHONE 360-898-2252 CONTRACTOR ADDRESS PHONE CONTRACTOR LICENSE LENDER INSPECTION INSP DATE Comments INSPECTION INSP DATE Comments Fireworks Inspection cs CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDlYYYY) 8/6/2024 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 CONTACT NAME: Janet Nau The Partners Group Ltd PHONE FAX 1111 Lake Washington Blvd N. 0 425-455-5640 vc No:425-455-6727 Suite 400 aoDRes : jnau@tpgrp.com Renton WA 98056 INSURERS AFFORDING COVERAGE NAIC a INSURER A:Everest Indemnity Insurance Co 10851 INSURED 15539 INSURER B:Everest Denali Insurance Company 16044 Wolverine West, LLC INSURER C:Arch Specialty Insurance Company 21199 Wolverine West Fireworks PO Box 628 INSURER D: Chehalis WA 98532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1251277431 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. NOTVVITHSTAN DING 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. IPOLICY EFF POLICY EXP NSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDJYYYY MMIDD/YYYY LIMITS LTRINSR A GENERAL LIABILITY Y S18GL02100241 2/1/2024 2/1/2025 EACH OCCURRENCE S_1,000.000 X DAMAGE TO RENTED - COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S 500,000 CLAIMS-MADE OCCUR MED EXP(Any one person) S Excluded PERSONAL&ADV INJURY S 1 000,000 GENERAL AGGREGATE $2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG S 2,000,000 POLICY X PRO- LOC S B AUTOMOBILE LIABILITY S18CA00276241 2/1/2024 2/1/2025 COMBINED SINGLE LIMIT Ea accident S11.000.000 ANY AUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS S XNON-OVVNED PR accident) OrPROPERTY DAMAGE EX HIREDAUTOS X AUTOS s C UMBRELLA LIAB OCCUR UXP105131601 21112024 2/1/2025 EACH OCCURRENCE $4.000.000 X EXCESS LIAR HCLAIMS-MADE AGGREGATE S 4,000,000 DED I I RETENTIONS S WORKERS COMPENSATION wC STATU- I JOTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) The following are included as Additional Insured on General Liability as their interest may appear as respects operations performed by or on behalf of the Named Insured per form ECG 20592 0509 Additional Insured-Designated Person or Organization attached: Alderbrook Resort&Spa,Mason County&its employees ATIMA are Additional Insured as respects the 11/29/24, 12/31/24 Aerial Fireworks Displays located at Alderbrook Resort&Spa,7101 E State Highway 106,Union,WA 98592. 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. Alderbrook Resort&Spa 7101 E State Highway 106 Union WA 98592 AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 11011s®c1ro,4•� APPLICATION DATE OF APPLICATION PART I r FOR PUBLIC FIREWORKS DISPLAY PERMIT 11/11/24 TO: Governingbodyof city, town,or countyin which display is to be conducted. APPLICANT NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628-Chehalis,WA 98532 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort&Spa 7101 E WA-106, Union WA 98592 360.898.2252 PYROTECHNIC OPERATOR NAME ADDRESS LICENSE# Chad Beebe 11210 Saskatoon Ln,Olympia,WA 98508 P-04245 NAME OF ASSISTANTS: at least one required) NAME ADDRESS AGE Aaron Webb PO Box 1120,Teni no,WA 98589 P-04311 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY _ LOCATION From the dock in front of Alderbrook Resort,7101 E WA-106, Union WA 98592 DATE 11/29/2024 TIME 5:00 pm+/- NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED [14] 1.2" comets- [15] 3" shells- [10]4" shells- [11] multi-shot cakes Call Chad Beebe to schedule an inspection 360.791.5055 MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines &10 v-L— SIGNATUtRE OF APPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) The Partners Group X❑ Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 1111 Lake Washington Blvd N. Suite 400 Bond or certificate of insurance shall provide minimum coverage of Renton, WA 98056 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II PERMIT PERMIT# DATE: In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a fireworks display as per the above application. NAME: (Full name of person,firm,or corporation granted permit) RESTRICTIONS: Permit not valid without verification of (Signature of Official granting permit) the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000-420-050(R 02105) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee �'yN\NOTQI/J f'� Washington State Patrol Fire Protection Bureau 11215P C. 0 Office of the State Fire Marshal Pyrotechnic Operator License P� Licensee Data WASHINGT Chad E. Beebe Phone Number: ( 761-5055 11210 Saskatoon Lane Southea,t + Email Address: pyrotecture@gmail.com Olympia, WA 98508 Date of ls!�.ue: January'31, 2024 License Plumber: P-04245 Date of Expiration: January 31, 2025 State Fire Marshal Licensee Signature 3W.470-0+1(10'18) Licensee Wall Mount Card MASON COUNTY (360)427-9670 Shelton ext.352 DEPARTMENT OF COMMUNITY DEVELOPMENT (360) 275-4467 Belfairext. 352 BUILDING• PLANNING• FIRE MARSHAL (360)482-5269 Elma ext. 352 Mason County Bldg. III, 426 West Cedar Street 78u PO Box 279, Shelton, WA 98584 www.co.mason.wa.us FIR209,4 - Mason 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: Alderbrook Resort & Spa Mailing Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone#: 360.898.2252 Email: cindy.sund@alderbrookresort.com Sponsor Information: Name: Alderbrook Resort & Spa Address: 7101 E WA-106 City: Union State: WA Zip: 98592 Phone#: 360.898.2252 Email: eric.sund@alderbrookresort.com Washington State Fireworks License Information (Copy Required): License Number: P-04245 Date of Issuance 1/31/24 Xpyrotechnic Operator License ❑ Fireworks Stand License Bond or Certificate of Insurance (Copy of Certificate/Bond Required): Provider: The Partners Group, Ltd. - attached Insured: Wolverine West, LLC Certified Holder: Alderbrook Resort & Spa Location of Stand/Display: Site Address: 7101 E WA-106, Union, WA 98592 Directions to Site: see attached Parcel Number: (twelve digit number) - -Fired on docks Puget Sound Legal Property Owner n/a "Please see reverse side to complete your application" The following pertinent information MUST be provided on the site diagram below Location and Setback distances from the back, sides and front of retail sales stands or designated display areas to: Fire Hydrants Property Lines Mortar separation distance Combustibles Parking Designated landing area Fire Lanes Public Roads and Right of Ways Trees/Brush Private Roads and Right of Ways Utilities Landmarks see attached aerial 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.Rodney F. Digitally signed by Rodney F.Hash DN:cn=Rodney F.Hash,o=Wolverine Signed West, d° Date 11/11/2024 nsk10.311 small=�nAfalwnlvarinewnct cnm c_IIS Date:2024.11.11 10:49:18-08'00' PART I IN Val APPLICATION oATEOFAPP�,�Ar,o� Ur FOR PUBLIC FIREWORKS DISPLAY PERMIT 11/11/24 TO: Governing body of city,town, or county in which display is to be conducted. APPLICANT NAME ADDRESS PHONE Wolverine West Fireworks PO Box 628-Chehalis,WA 98532 206.459.0917 SPONSOR ADDRESS PHONE Alderbrook Resort& Spa 7101 E WA-106, Union WA 98592 360.898.2252 PYROTECHNIC OPERATOR _ NAME ADDRESS LICENSE# Chad Beebe 11210 Saskatoon Ln, Olympia,WA 98508 P-04245 NAME OF ASSISTANTS: at least one required) NAME ADDRESS AGE Aaron Webb PO Box 1120,Tenino,WA 98589 P-04311 NAME ADDRESS AGE EXACT LOCATION OF PROPOSED DISPLAY LOCATION From the dock in front of Alderbrook Resort, 7101 E WA-106, Union WA 98592 DATE 1 1/29/2024 TIME 5:00 pm+/- NUMBER AND KINDS OF FIREWORKS TO BE DISPLAYED [141 1.2" comets - [151 3" shells -[101 4" shells- [111 multi-shot cakes Call Chad Beebe to schedule an inspection 360.791.5055 MANNER& PLACE OF STORAGE PRIOR TO DISPLAY Subject to approval of Local Fire Authority) In our approved magazines V4�0v-4— SIGNATUtRE OF APPLICANT FINANCIAL RESPONSIBILITY BONDING OR INSURANCE COMPANY (Mark One) The Partners Group ❑X Bond or certificate of insurance attached ADDRESS ❑ Bond or certificate of insurance on file with State Fire Marshal 1111 Lake Washington Blvd N. Suite 400 Bond or certificate of insurance shall provide minimum coverage of Renton,WA 98056 $50,000/$1,000,000 bodily injury liability for each person and event, respectively,and$25,000 property damage PART II PERMIT PERMIT# DATE: In accordance with the provisions of RCW 70.77 and applicable local ordinances, this permit is granted to conduct a fireworks display as per the above application. NAME: (Full name of person,firm,or corporation granted permit) RESTRICTIONS: Permit not valid without verification of (Signature of Official granting permit) the appropriate State Fireworks License (Title) LICENSE NUMBER: (Instructions on reverse side) 3000-420-050(R 02/05) Distribution: WHITE (A): Local Fire Authority; YELLOW(B): Permitee Ac" CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDYYYY( lkk � 8/6/2024 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 CONTACT NAME: Janet Nau The Partners Group Ltd PHONE FAX 1111 Lake Washington Blvd N. •425-455-5640 ac N0:425-455-6727 Suite 400 ADORES : inau@tpgrp.com Renton WA 98056 INSURERS AFFORDING COVERAGE NAIC# _ INSURER A:Everest Indemnity Insurance Co 10851 INSURED - _ 15539 INSURER B:Everest Denali Insurance Company 16044 Wolverine West, LLC Wolverine West Fireworks INSURERC:Arch Specialty Insurance Company 21199 PO Box 628 INSURER D: Chehalis WA 98532 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1251277431 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. INSR U Y LTR TYPE OF INSURANCE IN,U D POLICY NUMBER MM DD/YYYY) (MMIDDIYYYYI LIMITS A GENERAL LIABILITY Y S18GL02100241 2/1/2024 2/1/2025 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTE5 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocwrrence $500,000 CLAIMS-MADE �OCCUR MED EXP(Any oneperson) $Excluded _ PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 POLICY X I PRO- LO $ B AUTOMOBILE LIABILITY S18CA00276241 2/1/2024 21112025 COEa accident MBINED SINGLE LIMIT X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PPROPER nDAMAGE $ IAUTOS $ C UMBRELLA LIAB OCCUR UXP105131601 2/1/2024 2/1/2025 EACH OCCURRENCE $4,000,000 X EXCESS LIAB HCLAIMS-MADE AGGREGATE $4,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OER TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ NIA A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? _ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT S i I I i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101.Additional Remarks Schedule,if more space is required) The following are included as Additional Insured on General Liability as their interest may appear as respects operations performed by or on behalf of the Named Insured per form ECG 20592 0509 Additional Insured-Designated Person or Organization attached. Alderbrook Resort&Spa,Mason County&its employees ATIMA are Additional Insured as respects the 11/29/24, 12/31/24 Aerial Fireworks Displays located at Alderbrook Resort&Spa,7101 E State Highway 106,Union,WA 98592. 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. Alderbrook Resort&Spa 7101 E State Highway 106 AUTHORIZED REPRESENTATIVE Union WA 98592 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: S18GL02100231 COMMERCIAL GENERAL LIABILITY ECG 20 592 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) ANY PERSON OR LEGAL ENTITY IN WHICH YOU HAVE A WRITTEN CONTRACT, AGREEMENT, OR PERMIT WHICH REQUIRES THAT YOU NAME THE CONTRACTING PARTY AS AN ADDITIONAL INSURED. Alderbrook Resort&Spa, Mason County&its employees ATIMA are Additional Insured as respects the 11/29/24, 12/31/24 Aerial Fireworks Displays located at Alderbrook Resort&Spa 7101 E State Highway 106, Union,WA 98592. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to C. The Limits of Insurance afforded to an additional include as an additional insured the person(s) or insured shall be the lesser of the following: organization(s) shown in the Schedule, but only 1. The Limits of Insurance required by the written with respect to liability for "bodily injury", "property agreement between the parties; or damage" or "personal and advertising injury" but only to the extent caused, in whole or in part, by 2. The Limits of Insurance provided by this Cov- your acts or omissions or the acts or omissions of erage Part. those acting on your behalf: D. With respect to the insurance afforded to an addi- 1. In the performance of your ongoing operations; tional insured, the following additional exclusion or applies: 2. In connection with your premises owned by or This insurance does not apply to "bodily injury", rented to you. "property damage" or"personal and advertising in- B. The insurance afforded to an additional insured jury" arising out of any act or omission of an addi- shall only include the insurance required by the tional insured or any of its employees. terms of the written agreement and shall not be broader than the coverage provided within the terms of the Coverage Part. ECG 20 592 05 09 Copyright, Everest Reinsurance Company 2009 Page 1 of 1 ❑ Includes copyrighted material of Insurance Services Office, Inc., used with its permission. III rr � � S N } T Y n : i P' 1" s 11 A� Ju $3" To�8r40 Washington State Patrol Fire Protection Bureau G23746 Office of the State Fire Marshal General Display Fireworks License Licensee Data Operational Data Wolverine West, LLC In State Agents Rodney F. -Hash Post Office Pox 628 Phone Number: (206) 459-0917 Chehalis, WA 98532 Email Address: r-pd@wolverinewest.com License Number: C-04138 Date of Issue-February 21, 2024 Date of Ecpiration:January 31, 2025 LA State Fire Marshal Licensee Signature 3000.420-041(10118) I Washington State Patrol Fire Protection Bureau 11224P Office of the State Fire Marshal Pyrotechnic Operator License 44y4RSMiI'>t�t�4 Licensee Data Rodney F. Hash Phone Number:(206) 459-0917 Post Office Box 628 Email Address:rod@wolverinewest.com Chehalis, WA 98532 Date of Issue: February 21, 2024 License Number: P-04255 Date of Expiration: January 31, 2025 State Fire Marshal Licensee Signature 3000-420-043(10/18) Licensee Wall Mount Card _ F Washington State Patrol Fire Protection Bureau 11 2 1 5p :l `> Office of the State Fire Marshal f Pyrotechnic Operator License Ft4f ' i I, Licensee Data Chad E. Beebe Phone Number:(360) 701-6055 11210 Saskatoon Lane Southeast Email Andress:pyrotectul'e@gmail.com Olympia, WA 98508 Date of Issue: January 31, 2024 License Number: P-04245 Date of Expiration: January 31, 2025 <: State Fire Marshal Licensee Signature s .sao-n : '`'1"' Licensee Wail Mount Card