ANTHEM APPLICATION FOR FIREWORKS DISPLAY_REDACTED.PDF

MARICOPA COUNTY BOARD OF SUPERVISORS
301 West Jefferson Street, 10th Floor, Phoenix, Arizona 85003

APPLICATION FOR FIREWORKS DISPLAY

Arizona Revised Statutes § 36-1603 requires every display shall be handled by a competent operator, and shall be of a
character and located, discharged and fired so that it will not be hazardous to property or endanger any person. Before a
permit is granted, the operator, location and handling of the display shall be approved by the sheriff of the county. After a
permit is granted, the sale, possession, use and distribution of fireworks for the display shall be lawful for that purpose only.
Permits are not transferable or assignable.

Further, A.R.S. § 36-1604 requires that the governing body shall require each applicant to provide a satisfactory bond of
not less than $500, or a copy of the certificate of liability insurance in a principal amount usually not less than $1 million,
conditioned upon payment of all damages which may be caused to persons or property by reason of the display.

Complete the following application and submit to the Clerk of the Board of Supervisors, 301 W. Jefferson Street, 10!" Floor,
Phoenix, 85003 (602-506-3766) at least 30 days prior to the event date.

All applications must have the following documentation attached:
1. Proof of appropriate bond or insurance payable to Maricopa County.
2. Map of display area.
3. List of fireworks to be discharged. The Director of Display for the fireworks company is expected to be licensed
and/or trained by the City of Phoenix or have other verification of expertise.
4, Verification from local fire department that they were notified of event, date, location and time,

EVENT INFORMATIONName/Organization:Anthem
Name of Event: July 3rd, 2023 Fireworks Display
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086

Date and Time of Event:July 3rd, 2023 @ 9:00 PM —

DISPLAY DIRECTOR (permit will be issued to the following)

Name:Randy Reyman —0lUll

Business: Reyman Pyrotechniques/Any Pyro Fax: |

SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO:
Maricopa County Clerk of the Board of Supervisors Email: ClerkBoard@maricopa.gov

301 W. Jefferson Street, 10" Floor Fax: 602-506-6402
Phoenix, AZ 85003

For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766
FIREWORKS DISPLAY SITE MAP

Indicate the following:

Fire department access
Hydrants

Distance to structures
Overhead lines

RECEIVED

APR 04 2023

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

1. North direction

2. Distance from firing area to impact/fallout area
3. Spectator location

4, Storage area

ONO

(North)

FOR DEPARTMENT USE ONLY:
SHERIFF'S OFFICE RECOMMENDATION

The State Fire Marshal or local fire chief has reviewed the site and fireworks described by the applicant and found them to
be satisfactory.

Sheriff's Office Signature Date

er SE at

a8 Aa a PE SON APSE

PERMIT FOR FIREWORKS DISPLAY

The above application having been filed pursuant to A.R.S. § 36-1603, together with other proper documentation;
permission is granted to the above-named applicant to conduct a fireworks display on the dates set forth in the application.
IN THE EVENT OF POSTPONEMENT OF SAID SHOW, the display will be given not later than one (1) week from the date

specified above.

Approved by the Maricopa County Board of Supervisors on:

DATED this day of 20

Clerk of the Board, Authorized Signature

—
ACORD

CERTIFICATE OF LIABILITY INSURANCE

OATE (MIIDOYYYY)
3/9/2623

BELOW.
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,

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
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

certificate holder In lieu of such endorsement(s),

IMPORTANT: If the certificate holder js an ADDITIONAL INSURED, the pollcy(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

PROOUGER

CONTACT

NAME: | <i

Ryder Rosacker McCue & Huston (MGD by Hull & Company) PHONE
609 W Koenig St {AIG No. E
Grand Island NE 68801 ADDRESS: -
INSURER(S} AFFORDING COVERAGE NAIC E
a insurer A: SCOTTSDALE IND CO 15580
INSURED
iques / Any Pyro |
msurer . i
INSURER E: . i
INSURER F i
COVERAGES CERTIFICATE NUMBER; 1324103877 REVISION NUMBER:

EXCLUSIONS AND CONDITIONS OF

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 8Y THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS.
H POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,

A | GENERAL LIABILITY
x | COMMVERGISL GENERAL [JABILIEY

| | evamsanoe |X | oc
—|— CLams-Mage | A | OCCUR
|

GEN'L AGGREGATE LIMIT APPLIES PER:
_SEN Al :
_X[roucy; SR | lias

Insp 7 —_ ~ ASL SUBR’ POLICY EFF | POLICY EXP |”
LR! TYPE OF INSURANCE INSR WD POLICY NUMBER _ aA) (AMIDDINYYY) : -
CPROEAS75 an2o22 8912023 | EACH OCCURRENGE

“DAMAGE TO REATED
SES (Fa osciranca)

__ MEO EXE (Any one gerson}

| AUTOMOBILE LIABILITY

|

COMBINED SINGLE LTT
{Ea acadenty . 3 -

(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below

___| ANY AUTO
| ALL GYNED | SCHESULED
_, AUFOS (AUTeS
a 1 ) NONSOWNED
jfimeoaues _ | AUTOS a
$
_| UMBRELLA UAB | occur EACH OCCURRENCE $
__EXCESBLIAD) |_| CLAIMS: MADE GATE 3 a
_bED |__| RETENTIONS $
WORKERS COMPENSATION | WeSTATE Tore
| AND EMPLOYERS’ LIABILITY YIN LYOAYLIMITS | EBL
ANY PROPRIETORIPARTNERIE KEGUT IE GH ACCIDENT 8
| OFFICERIMEMSER EXCL UDEO? {NIA | a SMPLOYEE. ee
E.L.. DISEASE - EA EMPLOY

E.L, DISEASE - POLICY ¢

agreement,

agreement,

required by written agreement.

DESCRIPTION OF OPERATIONS / LOCATIONS} VEHICLES (Alfach ACORD 101, Additional Remarks Schodule, if more spaca is required)
Regarding the General Liability coverage, Waiver of Subrogation applies to the entitles listed below per attached form CG 24 04 when required by weitten

Regarding the General Liability coverage, Blanket Additional Insured applies to the entities listed below per attached form GLS-150s when required by venitten
Regarding the General Liability coverage, Primary and Non-Contributory coverage applies to the entities listed below per attached form CG 20 01 when
Additional insureds: Antham Community Council Inc, Asthem Parkside Community Association Inc.; Anthem Country Clu Community Association Inc.;

Maricopa County, State of Arizona, Daisy Mountain Fire District.; AAMLLC, their respective and affiliated entities and alt of their respective directors, officers,
pariners, menikers, employees, and agents are hereby named as additional insured, Insurance is primary and nencontributory. Display date is 07/03/2023

CERTIFICATE HOLDER

CANCELLATION ___

Anthem Community Council
3701 W Anthem Way Ste #201
Anthem AZ 85086

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED iN
AGGORDANGE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

ACORD 26 (2010/05)

© 1988-2010 ACORD CORPORATION. All rights reserved,

The ACORD name and logo are registered marks of ACORD

ACORD CERTIFICATE OF LIABILITY INSURANCE

fo

DATE (MMODIYYYY]
0212212023

THIS CERTIFICATE 15 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 have ADDITIONAL INSURED provisions or be endorsed,
lf 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 | Genet |
Ryder, Rosacker, McCue & Huston (ale. Ni. Ext LAE Wo
509 W, Koenig St. RObRESs: EEE
Grand Island NE 68801 INSURER(S} AFFORDING COVERAGE NAIC
- _ _| insurer a; Travelers Assigned Risk

INSURED INSURER Bt a =

Randy Reyman dba INSURER CG: =

iques/Any Pyro INSURE — a
INSURERE: Te
| 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. _

INSR TYPE OF INSURANCE isa POLICY NUMBER | pene ere | aioorery) units
_| COMMERCIAL GENERAL LIABILITY | EACH OCCURRENCE $
i _] CLAMS-MADE J OCCUR poe iy RENTED | ls 7
= MED EXP fAny one person) | $
ain PERSONAL & ADV INJURY | §
| GEN AGGREGATE LIMIY APPLIES PER: GENERAL ASGREGATE 3 |
POLICY hBS- Loc PRODUCTS - COMPIOP AGS | $
_OTHER: is
| AUTOMOBILE LABILITY Fas abel 2 7
ANY AUTO _ BODILY INJURY [Per person) | S
eee SCuRQULED BODILY INJURY {Per accicen:)| $ j
HIRED NON-OV/NEO PROPERTY DAMAGE $
|_} AUTOS ONLY AUTOS ONLY (Pet accident
| $
__) UMBRELLA LIAB | occur LEACH OCCURRENGE $
EXCESS LIAB CLAMS: AGGREGATE is
ven | RETENTION S $

Leola prt In NH)
5, descriie urdor
OR SERISTION SF OPERATIONS bolow

WORKERS COMPENSATION
AND EMPLOYERS’ LIABILITY vt
ANY PROPRIETORIPARTNER/EXECUTIVE|
A. | GFFIGERIMEMBER EXCLUDED? | YI|NIA 6JUB-5RB6638-5-22

x [EF ure | (ae -
E.L_ EACH ACCIDENT $ 1,000,000
E.., DISEASE - EA EmPLoyee| ¢ 1,000,000
EL. DISEASE - Pauicy et | ¢ 1,000,000

06/01/2022 |06/01/2023

| | |

DESGRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Romarks Schadule, may bo attachod if more space is ¢¢quired)

CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Anthem Community Council THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
3701 W Anthem Way Ste #201 ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem, AZ 85086 AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION, All rights reserved,

The ACORD name and logo are registered marks of ACORD

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Reyman Pyrotechniques/Any Pyro

Anthem 7/3/2023

Content of display

Following is the shell content of the display:
2 1/2 inch shells-70

3 inch shells-192

4 inch shells-160

5 inch shells-72

6 inch shells-24

MEMBER ii
RANDY L.
REYMAN

REYMAN PYROTEGHNICQUES ill! i Hil |
ih

Nwacitiitel ISS) AA OIC

isaued By

| Date Issued:

Daisy Mountain Fire Prevention

O18 N Daisy Mountain Brive Antien: Az. 85086 623-465-7400 May 2, 2022

Mr. Reyman,

Thank you for the notice from Reyman Pyro-Techniques/Any Pyro stating you will be
conducting the fireworks display for the Anthem’s July 3rd, 2023 event and that you
are aware you will need to obtain a DMFD permit for this event. A valid County permit
shall be obtained and DMFD standby will be required on the day of the event. We look
forward to working with you again. Please let us know if you need any further

information.

Sincerely,

Dave Vlichen

Dave Nielsen — Deputy Chief
Fire Prevention 623-465-7400

DAISYMOUNTAIN
41018 N DAISY MOUNTAIN DR

ANTHEM, AZ 85086

Permit Certificate DMFD
Date: 94/04/2023

Business Name: ANY PYRO

Address: 41130 N FREEDOM wy
1
Phone: SBFHEHQ2A84850653

The following permit has been issued:

Permit No. 2023-955 Type: FIREWRKS FIREWORKS SALES/DISPLAY
Issued Date: 04/04/2023 0
Effective Date: 07/03/2023 OCCUPANT LOAD:

Expiration Date: 07/03/2023

Applicant Information Company Name Reyman Pyrotechniques/Any

Pyro

Address 12820 S. 40th Pl.

Phoenix Az. 85044

Contact Person Randy Reyman

Email anypyro@msn.com

Phone 602-448-1033

Notes or Description of the construction or operations July

3rd Firework Display

It is the business's responsibility to ensure that conditions are in
accordance with applicable State and Local fire regulations.

Obtain any permits that are required by the State of Arizona and the
County having jurisdiction.

4/04/2923

Inspector: DMFD FIRE PREVENTION Date

04/04/2023 11:51 Page 1