ANTHEM FIREWORKS_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 Before
any person. 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
nol less (han $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., 2021 Fireworks Display
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086
Date and Time of Event: July 3rd., 2021 @ 9:00 PM
DISPLAY DIRECTOR (permit will be issued to the following)
Name:Randy Reyman non f —
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, 104 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:
1. North direction Fire
department access
2. Distance from firing area to impact/fallout area OO Hydrants
3. Spectator location Distance to structures
4. Storage area ON
Overhead lines

(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

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

a
DATE (MMIDD/YYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE
2/19/2024
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 Kri
Ryder Rosacker McCue & Huston (MGD by Hull & Compa | FAX
[ y a
Ext {AIC No}:
509 W Koenig St (AIC No.
Grand Island NE 68802 ADDRESS:
INSURER(S} AFFORDING COVERAGE NAIC #
INSURER A: SCOTTSDALE IND CO 15580
INSURED INSURER B :
eyman Pyrotechniques / Any Pyro
INSURERC:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1576402894 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
LTR TYPE OF INSURANCE INSR | Wvp POLICY NUMBER (MM/DDIYYYY) | (MMIDDIYYYY) LIMITS
A | GENERAL LIABILITY CPI0064560 8/9/2020 8/9/2021 EACH OCCURRENCE $ 1,000,000
x DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 100,000
| CLAIMS-MADE OCCUR MED EXP (Any one person) _| $5,000
PERSONAL & ADV INJURY _| $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
X | pouicy FRO: LOC $
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea accident) $
ANY AUTO BODILY INJURY (Per person) | $
AUTOS AUTOS. BODILY INJURY (Per accident) | $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE §
DED | | RETENTION $ $
WORKERS COMPENSATION WC STATU- OTH-
TORY LIMITS ER
AND EMPLOYERS’ LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEG| $
if yes, describe under
DESGRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Blanket Additional Insured applies to the entities listed below per attached form GLI-150s when required by written agreement.
Waiver of Subrogation applies to the entities listed below per attached form CG 24 04 when required by written agreement.
Additional insureds: Anthem Community Council inc.; Anthem Parkside Community Association Inc.; Anthem Country Club Community Association Inc.;
Maricopa County, State of Arizona, Daisy Mountain Fire District; AAMLLC, their subsidiary and affiliated entities and all of their respective directors, officers,
partners, members, managers, employees, and agents are hereby named as additional insured. Insurance is primary & noncontributory
Display date is 7/3/21
CERTIFICATE HOLDER : CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
AGCORDANCE WITH THE POLICY PROVISIONS.
; ;
Anthem Community Council
3701 W Anthem Way Ste #201
or UTHORIZED REPRESENTATIVE ENTA
Anthem AZ 85086
nm dere
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

aay
ACORID CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
Rename” 10/05/2020
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 have ADDITIONAL INSURED provisions or 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 endorsemeni(s).
PRODUCER CONTACT
Ryder, Rosacker, McCue & Huston PHONE FAX
C, No)!
509 W. Koenig St. E-MAIL
Grand Island NE 68801
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: [favelers Assigned Risk
INSURED
INSURER B:
Randy Reyman dba INSURER C:
Reyrnan Pyrotechniques/Any Pyro INSURER D:
INSURER E:
| INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS tS 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! ADDL SUBR POLICY EFF | POLICYE
LTR TYPE OF INSURANCE POLICY NUMBER AMDB) | uatarDY Limits 7
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $
[] DAMA\ Bea geReN TED
CLAIMS-MADE OCCUR $
MED EXP (Any one person) $
PERSONAL & ADVINJURY [|
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY FRO LOC PRODUCTS - COMP/OP AGG | §
OTHER: 8
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
heaccdent $
ANY AUTO BODILY INJURY (Per person) | $
OWNED SCHEDULED
RUTOS ONLY beets BODILY INJURY (Per accident)! ; $
HIRED NON-OWNED PROPERTY DAMAGE
|__| AUTOS ONLY AUTOS ONLY (Per accident) $
$
UMBRELLA LIAB
occur EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
| |
DED RETENTION S $
WORKERS COMPENSATION [before PER | OTH
AND EMPLOYERS’ LIABILITY x EE
YIN
A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT go i00000
|OFFICER/MEMBER EXCLUDED? NIA 6JUB-4N92392-4-20 06/01/2020 |06/01/2021
(Mandatory In NH) E.L. DISEASE - EA EMpLoyee| $ 100,000
if yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - Poticy umit | ¢ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
CERTIFICATE HOLDER CANCELLATION
Anthem Community Council SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
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 <MM>
haabes Le
|
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

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anthem shells
Reyman Pyrotechniques/Any Pyro
Anthem Display, 7/3/2021
Content of display
Following is the shell content of the display:
2 1/2 inch shells-28
3 inch shells-162
4 inch shells-108
5 inch shells-76
6 inch shells- 4
Page 1

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Pyrotechnics Permit
issued By: 22021006 _Fire Inspector
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Date Issued:

DAISYMOUNTAIN
41018 N DAISY MOUNTAIN DR
ANTHEM, AZ 85086
Permit Certificate DMFD
.
Date: 95/11/2021
Business Name: ANY PYRO
Address: 41130 N FREEDOM WY
ANTHEM, AZ 85086
Phone; OFFC 602-448-1033
The following permit has been issued:
Permit No. 2021-360 Type: FIREWRKS FIREWORKS SALES/DISPLAY
Issued Date: 05/11/2021 OCCUPANT LOAD: 0
Effective Date: 07/02/2021
Expiration Date: 07/04/2021
Due to the high wildfire danger this season, DMFD will be required
to charge additional fees to assure there is sufficient fire
apparatus for standby on the day of the event. Please be advised if
there is extreme wildfire conditions, extreme weather conditions, or
if there is an active large-scale emergency event the day of the
event, DMFD may have to cancel the fireworks 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, io Rae the State of Arizona and the County
Fag
having jurisdiction. a We
Ta
pase
Inspector: DMFD FIRE PREVENTION - Date 05/11/2021
AR AS
05/11/2021 15:54 Page 1

Site Safety Plan for Anthem July 3rd, 2021 Fireworks Display
Range safety persons: Randy Reyman, Scott Haeffner
Permits received from Maricopa County and Daisy Mountain Fire District. Permits on hand at
display.
Launch site: Anthem Parking lot. Please reference site plan.
Time of set up of mortar racks: 12:00 PM
Time of loading of mortar racks: 4:00 PM approx.
Fireworks under supervision at all times.
Mortar racks arranged in lines running East-West. Mortar racks stabalized by legs attached to
racks. Safety breaks in rack lines for safe evacuation if needed.
Fireworks will be fired manually with safety flares. Spotters will be used to identify shells that
do not burst. Spotters will notify Range Safety personnel immediately.
Radio communication with sponsor and other personnel available at all times. Radio person
assigned to radio communication only. Range Safety Personnel wiil report to radio operator in
the case of an emergency.
Thirty minute wait time following display before taking down the racks.