LEISURE WORLD COMMUNITY_REDACTED.PDF

MARICOPA COTY L3I1RD SUPERVIJORS
301 West Jefferson Street, 10th Floor, Phoenix, Arizona 85003
APPI' ,IC4''.TION 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,
10th 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: New Year's Eve Fireworks
Event Address: 908 S. Power Road, Mesa AZ 85206
Date and Time of Event: December 31, 2019 @ 10:00pm
DISPLAY DIRECTOR (permit will be issued to the following)
Name: Sarah Harris Phone: 480-948-0090
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address 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 th 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 5. Fire department access
2. Distance from firing area to impact/fallout area 6. Hydrants
3. Spectator location 7. Distance to structures
4. Storage area 8. Overhead lines
(North)
See Attached
lemail 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
azao I,/ 1.04 led M.ma P. Po, P. f,1 Ra. Pa, Re f Po) Oa. Pi/ Pv, 0.10. 0.41RM, Pat d ROO Psd Pa/Pa, Pa10. • RaI.P.m, f4a10,1 Ro. Fm. B..1.10 Pa, ',Of., PO Pr, Pad Pa, Peg POI/ rft 1.4s. 0,0 Pt. 1 Pt. FRO
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

EXHIBIT A
LEISURE WORLD COMMUNITY
Mesa
New Year's Eve
10:00 pm
Tuesday, December 31, 2019
6 -8 minute display
Total Aerial Effects 419
Total Shells 219 Total Effects in Basins 200
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 163 aerial shells and 200 basin effects.
1 %" - 2 FPA Premier Specialty Basins
3" - 163 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 49 — 3" aerial shells.
Desg-ned for the Lez5ure World commwq9 Ly: Fireworks froductions of Araona

DATE (MMIDD/YYYY)
AcciRD CERTIFICATE OF LIABILITY INSURANCE 11/18/2019
krass../---
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 (NC, No): 425455-6727
11225 SE 6th St., Suite 110 (A/C. E-MAIL No. Ex
Bellevue WA 98004 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : T.H.E. Insurance Company 12866
INS URED 16021 INSURER B: Travelers Property Casualty Co of America 25674
F, PA LTD INSURER C:
Fireworks Productions of Arizona
17034 S. 54th Street INSURER D :
Chandler AZ 85226 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 466963777 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. NOTVVITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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 ADDL 1NSR SUER WVD POLICY NUMBER (MM/DD/YYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS
LTR
A GENERAL LIABILITY Y CPP010586203 10/9/2019 10/9/2020 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES TO (Ea RENTED occurrence) $ 500,000
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ N/A
X $2000 Deductible PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 10,000,000
GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
$
POLICY X FM- LOC
A AUTOMOBILE LIABILITY CPP010586203 10/9/2019 10/9/2020 COMBINED (Ea accident) SINGLE LIMIT $ 1,000,000
BODILY INJURY (Per person) $
ANY AUTO
ALL OVVNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS NON-OVVNED PROPERTY DAMAGE $
X HIRED AUTOS AUTOS (Per accident)
$
A UMBRELLA LIAB X OCCUR ELP001232903 10/9/2019 10/9/2020 EACH OCCURRENCE $ 9,000,000 GL Onl
X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 9,000,000 GL Onl
DED RETENT ON $ $
B WORKERS COMPENSATION 1K643590 — Arizona 10/9/2019 10/9/2020 X TORY VVC STATU- LIMITS 0TH- ER
AND EMPLOYERS' LIABILITY Y / N E.L. EACH ACCIDENT $ 1,000,000
ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? N / A
(Mandatory in NH) EL DISEASE - EA EMPLOYEE $ 1,000,000
If DESCRIPTION yes, describe under OF OPERATIONS below EL. DISEASE - POLICY LIMIT $ 1,000,000
A Auto Excess Liability - Occurrenc ELP001291101 10/9/2019 10/9/2019 10/9/2020 10/9/2020 Each Each Occ/Agg. Occ/Agg. $4,000,000 $5,000,000
A Auto Excess Liability - Occurrenc ELP001291201
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: December 31, 2019
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
908 S. Power Road AUTHORIZED REPRESENTATIVE
Mesa AZ 85206 ,. _' ,1
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

Site
Fireworks Map
611992
1 2
Water Class
Productions Fire 2-A
Display
of Site Extinguishers PreiatiriZed ,
Arizona
Maximum - - I
Ima
Shell e
480-948-0090 Dare:
Size:
3" 3/13/2013
Shells
33°23'45.77"
N
info@fireworksaz.com 111'42'12.02"
W
elev
Mesa, Leisure
‘J J. AZ World
I L

Mia Vargas (COB)
From: Sarah Harris <sarah@fireworksaz.com >
Sent: Tuesday, December 3, 2019 8:59 AM
To: Mia Vargas (COB)
Subject: FW: EXT: Permit Request
Please see below the email from the responding fire department.
Pyro Office Manager
Pyrotechnician
t!uvor
Pr-mita:60w
of ArizoniJ
480-948-0090 (office
480-423-5430 (fax)
1-877-948-0090 (toll-free
17034 S. 54th Street, Chandler, AZ 85226
From: Diamond, Kenneth [mailto:Kenneth.Diarriond@ruralmetrofire.com]
Sent: Monday, December 02, 2019 4:38 PM
To: Sarah Harris
Subject: RE: EXT: Permit Request
Hello
We are aware of the fireworks display on New Years Eve at 908 S. Power rd Mesa, AZ
We are the AHJ and responding fire department of the area.
Kenneth Diamond
Fire Captain
Deputy Fire Marshal
Rural/Metro Fire Central Arizona
7631 E. Main St Mesa, AZ 85207
C: 480.869.2340

0: 480.380.3700 x Option 4
From: Sarah Harris <sarah@fireworksaz.com >
Sent: Friday, November 22, 2019 2:12 PM
To: Diamond, Kenneth <Kenneth.Diannond@ruralmetrofire.com >
Subject: EXT: Permit Request
Hello Sir,
Attached is the permit request for the Leisure World Community New Year's Eve fireworks display. If you have any
questions please do not hesitate to contact our office. Thank you
Sarah
Pyro Office Manager
Pyrotechnician
Firewor
Production;,;
Ari.totiii
480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)
17034 S. 54th Street, Chandler, AZ 85226
CAUTION: This email originated from outside the GMR organization. DO NOT click links or open attachments unless you
recognize the sender and know the content is safe. NEVER provide your User ID or password. If you have any questions,
please contact the GMR Help Desk @ 1-866-267-9111
Virus-free. www.avg.com
2