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DOCUMENTS ®Harnett COUNTY * ® ---, Plan Review, Inspection, and Permit Fees Application Number : 17-500.41487 $200.00 ❑ Explosive Material (90 Days) $ - $100.00 ❑ Explosive Materials (72 Hours) $ - $100.00 O Fireworks Public Display $ 100.00 $50.00 ❑ Final Inspection $ - $35.00 +$2.00 per device ❑ Fire Alarm Testing $ . $35.00 +$2.00 per nozzle ❑ Fixed Fire Suppression $ - $75.00 ❑ Insecticide Fog/Fumigation $ - $100.00 ❑ Pipe Test/UST/AGST $ - $50.00 ❑ Plans up to 5000 sq ft $ - $100.00 ❑ Plans 5001 sq ft to 10,000 sq ft $ - $150.00 ❑ Plans 10,001 sq ft to 25,000 sq ft $ - $250.00 ❑ Plans 25,001 sq ft and over $ - $35.00 +2.00 per head ❑ Sprinkler Certification Test $ - $50.00 ❑ Standpipe Testing $ - $50.00 ❑ Special Assembly (le.amusement buildings,carnivals,fairs) $ - El $75.00 Tents/Canopies/Air Supported Structure $100.00 Tank Installation (charge for each tank) $ $100.00 ❑ Tank Removal (charge for each tank) $ - Total Devices/Heads $ . Total Cost $ 100.00 Code Enforcement Official Rodney Daniels 5/26/2017 Harnett m COUNTY (FM> E•.,.K,Sans verretharnett� Fire Marshal Division May 26, 2017 Chris Prince East Coast Pyrotechnics PO Box 209 Catawba, SC. 29704 Carolina Lakes 91 Club House Drive Sanford, NC 27332 Application Number 17-50041487 Mr. Prince, The application for the outdoor public display of fireworks for the Carolina Lakes has been reviewed and approved as submitted. The public display shall be in accordance with the NC Fire Prevention Code and NFPA 1123, Prior to the issuing permits for fireworks display, a compliance inspection of the display site and demonstration of the display operation shall be approved. The compliance inspection will be conducted before the time of the show. • Fire Protection for Fireworks o Portable fire extinguisher shall be placed at the discharge area and standby fire apparatus shall be placed down range for fall out. o Contact shall be made with the local Fire Department to establish terms for standing by with apparatus and personnel. o Confirmation with the local fire department shall be returned to this office. o Shoot time has been established for July 3`", 2017 at 9:30 pm, if changes are made contact needs to be made to this office by 910-984-6294 (Rodney Daniels). o Fireworks must never be left unattended. • Distance o At least 70 feet for diameter inch of shell must be provided between the shoot site and the public (4" largest mortar=280 feet) • Permits o Final inspection will be conducted that day of the event and the permit will be issued. • ® Harnett COUNTY • ..r.Arnw..ry • Setup o You may contact our office for a representative to meet on site during setup or for any additional questions that may arise. (910) 893-7580. • 8.1.3.4* During the faring of the display, all personnel in the discharge site shall wear the following: o Head protection o Eye protection o Hearing protection o Foot protection o Cotton, wool, or similarly flame-resistant, long-sleeved, long-legged clothing • 8.1_1* The sponsor shall consult with the AHJ and the operator to determine the level of fire protection required. • 8.1.2* The following shall apply to crowd control: o Monitors whose sole duty is the enforcement of crowd control shall be located around the display site and at other locations as determined by the sponsor. o The AHJ and the operator shall approve the provisions for crowd control. • 3308.8 Fireworks Display Supervision. Whenever in the opinion of the fire code official or the operator a hazardous condition exists, the fireworks display shall be discontinued immediately until such time as the dangerous situation is corrected. Thank you again for submitting the plans for the Carolina Lakes fireworks display. Please review the plans and adhere to any notes and alterations that were made in addition to the original drawings. These remarks are for the plans that were submitted and its original intent. These remarks do not apply if the original intent changes or what was submitted on the above date changes. If you have any questions, please do not hesitate to call this office Sincerely, inR . Rodney Dan IIs Chief Deputy Fire Marshal • Harnett —11Th COUNTY �'► h04i• :A,k^CCNA �� em...u,rsr.in.GNrgrnt vanchanntiawg Fire Marshal Division FIREWORKS APPLICATION Attached you will find an application for a Fireworks Discharge Permit. This application must be completed and returned to Central Permitting prior to issuance of the permit. PLEASE ALLOW FIVE(7-10)WORKING DAYS FOR PROCESSING.There is a 25.00 permit fee assessed per discharge event. Permit fees shall be paid prior to issuance of permits. If you have any questions, please feel free to contact us. ITEMS REQUIRED PRIOR TO PERMIT ISSUANCE: I. All blanks must be completed on the application. 2. The Permit Holder is required to obtain liability insurance in an amount sufficient to cover the claims of any person(s) who may be injured or otherwise damaged as a result of the display. The insurance must name Harnett County as an additional insured and a copy of the Certificate of Insurance evidencing the coverage must accompany the application. ( Amounts will be determined by event ) 3. Include a detailed site plan indicating the discharge and storage locations and distance. 4. Include the manufacturer's technical data sheet of each type of pyrotechnics to be discharged. SECTION EXPLANATION: Section I: Information on the person, group, corporation, association, or entity sponsoring, holding, or primarily responsible for the event Section II: Information on the Pyrotechnician Section III: Information on the actual display Section IV: Public Safety Information. (Name of fire district where the discharge will take place, address of the nearest fire station, and name and location of the nearest medical facility.) Section V: Notarization of the application.(APPLICATION SIGNATURES MUST BE NOTARIZED.) Section VI: Fire Department Comments. (This must be completed by the Chief of the local fire department representing the district where the discharge will take place Section VII: For Harnett County Fire Marshal use only Section VIII: Fireworks Permit Number. THE FIREWORKS PERMIT MUST BE ON SITE DURING THE DISCHARGE OF THE PYROTECHNICS. Harnett COUNTY 1 eaw�rt««.to..dw.ee.m AOAU I MI yank t.� IMPORTANT: THIS APPLICATION MUST BE RETURNED NO LATER THAN FIVE (5) WORKING DAYS PRIOR TO EVENT TO ENSURE PERMIT PROCESSING. PLEASE TYPE OR PRINT APPLICANT INFORMATION: (Note: The applicant is the person, group, corporation, association, or other entity sponsoring, holding or primarily responsible for the event or enterprise for which this permit is requested.) Name: East Coast Pyrotechnics Telephone: 803-789-5733 home Address: P O Box 209 803-789-5733 work Catawba, SC 29704 For a corporate applicant, indicate the name and address of the registered agent for service of process: Name: Joel Matthews! oeI©eastcoastpyro corn Address: P.O. Box 209 Catawba, SC 29704 President or CEO: Tom Thompson Indicate whether the applicant is or will be insured with respect to the discharge of fireworks/pyrotechnics: YES XX NO If covered, specify the source, amount, and coverage period of the insurance: Source:Britton-Gallagher & Assoc Amount: $ 5,000,000.00 Coverage Period: 3/30/17 to 3/30/18 --41.,n Harnett �.,n iOUNTY * A �'►, Focr- .�,eo.�u�, �FMf t:,t.y.t„s„.ta..awtt.ae 1' wrodur wt,arq PYROTECHNICS TECHNICIAN INFORMATION: (Note: This is to he completed by the individual who will shoot and/or discharge the fireworks or pyrotechnics.) Name: Chris Prince "telephone: (919) 324-5096 home Address:306 Womble Drive (919) 324-5096 work Lillington, NC 27546 Bureau of Alcohol, Tobacco and Firearms permit/license type and no.: *scree1-5,.eem22a Specify Pyrotechnicians' training and experience: NC Licensed Operator #1927, over 7 years experience. Past displays Carolina Lakes POA, Campbell University and Town of Cleveland Indicate whether the technician is or will be insured with respect to the discharge of fireworks/pyrotechnics: YES XX NO If covered, specify the source, amount, and coverage period of the insurance: Source: Britton-Gallagher & Assoc Amount: $ 5,000,000.00 Coverage Period: 3/30/17 to 3/30/18 nHarnett COUNTY * A A r En�xEancr 4nim Departmentneeu. rIFMA wrhada; �}� w .liarmrc.orE �y i . . f _. DISPLAY INFORMATION: ( Note: Indicate who provided this information:) Applicant: XX Technician: Both: Indicate the type of display event: Carnival: Exhibition: Fair: Public Celebration: XX Other: Proposed day and time of the event: Day: 7/3/17 Time: 9:30pm AM / PM Proposed location or site: Carolina Lake at Pavilion (see attached) Specify the type and quantity of the fireworks/pyrotechnics to be used and the sequence of the discharge/shooting: (8) 3/4" to 2 1/2" Caliber Multi-Shot Cakes 160 - 3" Caliber Shells 85 - 4" Caliber Shells 90 - 3" Caliber Finale Shells Harnett COUNTY S ® 1107 'r,r:.:nn EaaDepartmentS�. Department !r' with/meta. Estimated duration of the display: 14 to 15 minutes Specify any safety precautions to be taken: Follow all NFPA 1123 , North Carolina and Harnett County guide lines. All technicians will have all Personal Protection gear (ear plugs, safety glasses, proper cotton clothing, etc) taint If 4.PUBLIC SAFETY INFORMATION: The display will occur within the following fire district: Spout Springs Location of the nearest fire station: Station 1 Spout Springs Name and location of the nearest medical facility: Name: Cape Fear Valley Hospital Location: Fayetteville, NC • as Harnett Y O CUNTTY * S C O :A F.GoiFM) wmMnt Ems'deg rims D.pa rl WMI��Ii�Mh.Of9 FIRE DEPARTMENT COMMENTS: (Note: To be completed by local fire department representing the district in which the discharge will w.illlttake place.) vis $72647 C.372/ je 441 c re cew ern NP 4 /Jrt4 d' 7•1437 1.4i pt �C h a v / 4 /Vat_ re-Gare Recommendation: Approve: Disapprove: Chief's Signature: Date: FOR OFFICE USE ONLY FIRE MARSHAL COMMENTS: See 1714 f4'i to c,., 4c ja-c. FINAL APPROVAL: APPROVED: DISAPPROVED: Conditional approval and/or special conditions: Fire(Deputy) Marshal Signature: Date: Srl/ Z4' //fry ,ten Fireworks Permit No. /7- Soa 'f/[ r7 • I 4C9ROB CERTIFICATE OF LIABILITY INSURANCE 21/2017 DATE 1/ IMMDDMTYI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLLDER. 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(les)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 endorsemengs). PRODUCER CON ACT Britton Gallagher PHONE ---- One Cleveland Center, Floor 30 �A( FAX --_ -- --- E-MAIL No F•IL718-RSR-IL 71 D0 AMC,Noy 1375 East 9th Street ADDRESS; _ Cleveland OH 44114 INSRERISI AFFORDING COVERAGE NAIL ,�,,'�,' INWRED INSURER AA1anrm IndemnityCompany .__ H20743—. INSURER B:Rivarpart lnsuranurance__Co, East Coast Pyrotechnics Inc. INSURER C.Everest indemnity lncuranc®_C0. P.O. Box 209 -- -- 114fl51 __ Catawba SC 29704 INSURER 0 Fverest Natinnaj Insurance_Company INSURER E' INSURER F: COVERAGES CERTIFICATE NUMBER:1507011199 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. (NSR I -_- _.ADDLISIBINT TYPE OF INSURANCE POLICTEFF j M/DDI E IP WY - - - ---- --- LTR I(NSR MID POLICY NUMBER IMMID017 UMMDW1YYYII UMW C ,GENERAL LUa1LITI T 'SIBML(1(1005-1]1 13/30/$01] 3/30/2018 EACH OCCURRENCE 151,000,000 D K 1COMMERCIAL GENERAL LIABILITY j 1 PREMISESGE � Einncet8500,000__ CLAIMS.MADE !X OCCUR -- 1 MED EXP(Any one Perwn) $ --. -.- -__ PERSONAL&ADV INJURY 51,000 000 --- - - - GENERAL AGGREGATE 52000.000 GE N'LAGG0.EGATE LIMIT APPLIES PER PROpULi9COMP/OPAGG_ 53,000,000 POLICY Ix JECOT LOC ❑ AUTOMOBILE DABILIttf Y SISCA00005-171 3/30/2017 •3/30/2018 `(Ea p UO SCINEmIpSINGLE LIMI/ 0,000,000 X I ANY AUTO BODILY INJURY l 5 r'ALL OWNED I SCHEDULED 1 I (Per _ . 1_1j AUTOS I_ AUTOS BODILY INJURY IP scddwde'111 8 NN-0wNED -- -. — X HIRED AUTOS1 PROPERTY DAMAGE I JLxAUOTOS I I ,fPer AmdJn� _ __ $ A UMBRELLA LMB 1X OCCUR Y j EXC6020405 3/30/2017 l 3/30/2018 EACH OCCURRENCE $4,000,000 r_.1X I EXCESS LMS ICLAIMSMADE AGGREGATE 184,000.000__ — - I DEC RETENTIONS I I 5 B WORKERS COMPEN6AlIW WC3984013151 WASTER) 19/30/20189/30/2017 IX WCSTATU- OTH- AND EMPLOYERS LIABILITY TORY LIMES___ ER YlN ANY PROPRETOR/PARTNEREXECUTIVE ' EL.EACH ACCIDENT 51000.000 OFFICERMEMBE R EXCLUDED, NIA. IMppMMory 1n NHI EL.DSEASE-EA EMPLOYEE 51000,000 DESCRIPTION OF OPERATIONS below I DEL DISEASE-POLICY LIMIT SI 000,000 • DESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES IAMO ACORD 1111,AJMIonaI RenyrIs Sbsmon.epspace Is nqulndl Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. DISPLAY DATE. JULY 3, 2017 ADDITIONAL INSURED: 1)HARNETT COUNTY 2)CAROLINA LAKES PROPERTY OWNERS ASSOCIATION CERTIFICATE HOLDER CANCELLATION ANY OFE CAROLINA LAKES PROPERTY OWNERS ASSOCIATION THELD EXPIRATIONH E DATE THEREOF.AOVEENOTICEI ES WILL OBECELLDELVERED RIN 91 CLUBHOUSE DRIVE ACCORDANCE WITH THE POLICY PROVISIONS. SANFORD NC 27332 AUTHORIZED REPRESENTATNE y J ®19884010 ACORD CORPORATION. All rights reserved. ACORD 26 1101was) The ACORD name and logo are registered marks of ACORD . NCDOI OSFM I Fire Safety Programs - Code Officials Pyrotechnic License H... Page 1 of 2 MIKE CACISFY ' :Ftaeuasl1A rrX" -tYPaFr y3( HOME ABOUT US 05FM DIVISIONS DEPARTMENT OF INSURANCE CONTACT US EMPLOYMENT O5FM 24 NOTICE rL ri.. IIIH kF.alliN We have moved tothe en 9ull61np on 325 N. 99-12ry SONO Raleigh,NC.Our mailing address will 0 ...1. assistlllae 1302 Mail Service Center,Releloh NC])699-1203,Ploea call our mato pumper lar assistance-919-647-0000. d .l r N".iPCn Iv NEN'.11 F Fire Safety Programs FIRE SAFETY PROGRAMS"PYROTECHNIC LICENSE INFORMATION Pyrotechnic License Information Current Pyrotechnic License Holders Select License type urlmel-es. License Type License level Pyrotechnic I 36 y Operator O lyrotechnic I ac 2 Assistant O Proximate Audience I. IIMIIMIW -Get List Gm License Holder Information Pyrotechnic I.'cense Number Driver's License Number 527 i f I Search forLicensee Holder's Full Name:Christopher Robert Prince Business Name: East Coast Pyrotechnics Government ID By:North Carolina Government ID Type:Driver I.'cense ID Number: ***66677 II ca".00pher License Number: 1927 rix License Type: 1.30 Pyrotechnic License Level:Operator ] license Status:Val id Expiration Date:05/132018 Get a list of license holders by Last Name or Business/Employer last Name Business/Employer Search for List http://www.ncdoi.com/OSFM/Fire_SafetyPrograms/Default.aspx?field I=Cod... 5/15/2017 • T a Z .r' y NSN m o o ` S -�.. n 0 CU w t k z r N N C' .. . ♦-' N C N » o m v rD N _. !ik W Q v E < to r N Z' p O d P. D ,-. VV a5 r < • o m to F 0 m am ro co m D N in N 1. 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