LEISURE WORLD COMMUNITY_FIREWORK 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 INFORMATION
Name/Organization: Leisure World Community
Name of Event: Community event 50th Anniversary

Event Address: 908 S Power Rd, Mesa AZ 85206
Date and Time of Event: Saturday, March 11, 2023 @ 7:45pm

DISPLAY DIRECTOR (permit will be issued to the following)

Business: Fireworks Productions of Arizona Fax:
Address: 17034 S 54th St., Chandler AZ 85226 Email:

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

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

For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766.

FIREWORKS DISPLAY SITE MAP
Indicate the following:

1. North direction

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

4. Storage area

Fire department access
Hydrants

Distance to structures
Overhead lines

2 on

(North)

(eg email to Clerk of the Board

FOR DEPARMENT 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

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:

DATED this. day of 20.

Clerk of the Board, authorized signature

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EXHIBIT A

LEISURE WORLD COMMUNITY

Mesa

50° Anniversary

Saturday, March 11, 2023
15 minute display

Total Aerial Effects 674
Total Shells 374 Total Effects in Basins 300

Opening:
Leisure World's fantastic celebration of the New Year begins with an impressive
series of powerful booms and fiery, gorgeous color to excite and thrill your guests.

7 - 3” Color Shells

Aerial Display:
A large assortment of brilliantly-colored shells, including Chrysanthemums, Waves,

Crowns, Peonies, Brocade Crowns, Diadems, and Crossettes in gorgeous Reds,
Yellows, Blues, Greens, Silvers, and Golds.

Your Aerial Display will contain a total of 297 aerial shells and 300 basin effects.

1% - 3 FPA Premier Specialty Basins
3” - 297 Chinese Fancy’s & Specials

Grande Finale:

Your celebration will close in spectacular excitement as multiple styles of brilliantly-
colored shells, rocket skyward growing and glowing in breath-taking Blues, Golds,
Greens, Silvers, Yellows, Purples and Red.

Your Grande Finale consists of 70 — 3” aerial shells.

Designed for the | eisure World Community by: Fireworks Productions of Arizona

DATE (MMIDDIYYYY)

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ACORD CERTIFICATE OF LIABILITY INSURANCE = wor

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 net Nau
The Partners Group Ltd a — fa
11225 SE 6th St., Suite 110 MC —_—=-—
Bellevue WA 98004
INSURER(S) AFFORDING COVERAGE _ NAIC #

INSURER A: Everest Indemnity Insurance Co 10851
PA LTD 16021! insurer B : Everest Denali Insurance Company 16044
Fireworks Productions of Arizona INSURER C : AXIS Surplus Lines Insurance Company 26620
17034 S. 54th Street INSURER D; Travelers Property Casualty Co of America 25674
Chandler AZ 85226 INSURER E:

INSURER F :
COVERAGES CERTIFICATE NUMBER: 603044484 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 [ADDL |SUBR| POLICY EFF | POLICY EXP
LIR TYPE OF INSURANCE INSR | WvD POLICY NUMBER, {MM/DDIYYYY) | (MM/DDIYYYY) LIMITS
A | GENERAL LIABILITY Y $18ML.02344221 40/9/2022 10/9/2023 | EACH OCCURRENCE $1,000,000
ia DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 500,000
CLAIMS-MADE MED EXP (Any one person) _| $/A
PERSONAL & ADV INJURY _| $ 4,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
pouicy | X | SRS Loc s
COMBINED SINGLE LIMIT
8 | AUTOMOBILE LIABILITY ‘S18CA00258221 40/9/2022 torsiz0z3 | COMBINED § $4.000.000
X | any AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED i
ALL OM [| SCHED BODILY INJURY (Per accident) | $
rx | [x | NON-OWNED PROPERTY DAMAGE 3
HIRED AUTOS AUTOS (Per accident)
$
c UMBRELLALIAB | X | occuR P00100069169702 40/9/2022 10/9/2023 | EACH OCCURRENCE $ 4,000,000
X | EXCESS LIAB CLAIMS-MADE, AGGREGATE $ 4,000,000
veo |__| retentions $
D | WORKERS COMPENSATION GR08411 40/9/2022 roreroes (X | WESTATU-T [OTE
AND EMPLOYERS’ LIABILITY YIN TORY.LIMIT ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 4,000,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE] $ 1,000,000
Ifyes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 4,000,000
A_ | General Liability & SI8EX01790221 40/9/2022 40/9/2023 | Each Occurrence $5,000,000
Auto Excess over $4M Aggregate $5,000,000

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, as required by written contract:

Date of Display: March 11, 2023

Location of Display: Coyote Run Golf Course at Leisure World Community, Mesa

Additional Insured(s): State of Arizona; Maricopa County; Rural Metro Fire Department; Leisure World Community Association, Coyote Run Golf Course.

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.

Leisure World Community Association
£08 S. Power froad AUTHORIZED REPRESENTATIVE

carl faahhrnr—

© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

Mia Vargas (COB)

i SES Sent cage sR
From: Diamond, Kenneth ia
Sent: Friday, January 20, 2023 3:00 PM
To: Cindy Herbel
Subject: Re: Fireworks - March 11 - Leisure World

Hi Cindy
| am aware and approve of your shoot on March 11th.
Thank you

Get Outlook for Android

From: Cindy Herbel
Sent: Wednesday, January 18, 2023 2:19:39 PM

To: Diamond, Kereta

Subject: EXT: Fireworks - March 11 - Leisure World

Hello,
Leisure World is having a 50" Anniversary display for their community on Saturday, March 11. I’ve attached the

following information about the display:
e Rural Metro Notification Letter
e Show Program
e Site Map
e Col

When you get a chance after reviewing the material, please send a reply letting us know that you have no objections to

the display. | will include that
With the permit application to Maricopa County.

Thank you!

Cindy Herlel

Pyro Administrative
Assistant

“Fireworks
Productions
of Arizona

480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)

17034 S. 54th Street, Chandler, AZ 85226